Mary Kuntz: Hi, Paul. Thanks very much for joining us today. You’ve spent the past twenty years working in some of the poorest places on earth, and, over that time, you’ve written a lot about inequality and health care. How has that connection affected your work?

Paul Farmer: I think in a way starting in difficult places like a squatter settlement in central Haiti has been very helpful to our work because there’s an extremity there in terms of the health status of people and what’s available to them that you just have to confront early on. There isn’t health infrastructure. There aren’t people there to deliver health services whether prevention or care. And, yet, that’s precisely where the sickest people are. I think looking back to 20-something years ago, it was because we started in that setting that we had to develop models that would work in places with very scant health infrastructure and knowing that we would build it over time. But that there was a lot that you could do—immediately. Train local people to be community health workers. Erect modest facilities and try to provide high quality care. That’s how it started for us in Haiti. And really, that’s the model we’ve taken to the other nine countries in which we work.

Mary Kuntz: It sounds as though you needed to deal with issues that many people might not consider medical like housing and water and things like that.

Paul Farmer: That is true. There’s two ways to look at this I think as a physician or a provider of services. If I’m in a Harvard training hospital and I’m a surgeon, then no one’s going to expect me to diagnose and treat the disease, but also build the operating room and find electricity and supplies. But, that’s very much what we have to do.

So, there is that side of the model. And that leads, as you’ve said, to listening hard to what patients say about their other problems. If you have someone who has typhoid, they got that because they don’t have clean drinking water. So, you could keep spending your whole life treating typhoid, which can be a fatal disease as you probably know. Or you can treat typhoid and try to put in clean water.

Mary Kuntz: Was it difficult to convince funders that part of your mission should be things like houses and roads and water?

Paul Farmer: It’s still difficult to convince funders that what we need is about houses and water and jobs and food security. In fact, I would say that’s the most difficult part of our work—persuading funders what’s important.

Mary Kuntz: You’ve focused a lot of your work on chronic diseases like AIDS and tuberculosis. What was it like treating AIDS in the 80s? You were working in Haiti and people forget that back then, Haitians were considered their own risk group along with IV drug users and homosexuals. How did Partners in Health approach that problem?

Paul Farmer: We needed to show what really were the true risk factors for HIV and we did that by taking care of people of course. But, also by trying to find out what exposures they’d had. What about their lives were different from, say, the rural poor who did not have HIV? And that’s a pretty standard approach to this.

We also tried to publish what we were finding to be the nature of the risk, which was around poverty and inequality and population displacement. Now, later, this would be shown to be true across the world including Southern Africa where people migrate in labor migration pools to work in mines, say. And that’s what disrupts their stable family unit. And that’s what puts them at risk for acquiring HIV away from their homes.

Mary Kuntz: So how do you adapt to a setting like that? What’s your model and how is it different from what was done before?

Paul Farmer: Well, we try to do four things. One is to go in and rebuild public infrastructure because a lot of these clinics and hospitals have been neglected. And, make a strong effort to assure that people have modern medical infrastructure. What’s that mean? That means a clinic with a laboratory in it, electricity, etcetera. The second thing we do is try to start taking care of people right away because in these regions where there haven’t been many medical services, you have a backlog of very sick people no matter what disease we’re talking about. To do that effectively, we have to do a third thing, which is to train local people to do the work and the cornerstone of our model has been to train community health workers. These are lay people who are trained by us and they are stipended and paid by us. And they report to Partners in Health and the public sector authorities. And so, you suddenly find that if you’ve done those three things that you have a whole cadre of hundreds of people willing to do health work. It’s probably the best model for chronic disease, period. If you break your arm, it’s one thing. You get your arm set. Hopefully, it heals. But, if you have diabetes, say, or major mental illness or AIDS, then you’re going to need people to help you along the way for a long time. We call that accompaniment. Our health workers accompany their neighbors. The fourth thing that I mentioned earlier is we also try to do research to find out what’s going on. What are the dynamics of disease in this particular community? And how can we attack ever more distally to get at the roots of disease.

Mary Kuntz: How has the model changed since you started 20 years ago?

The big change has been, I’d say, ten years ago, when we had a reflection of what are we doing in Haiti? And what are we doing right and what are we doing wrong? We decided that what we were doing right was to provide quality services for people living in poverty. But, what we were doing wrong was not to ensure that it happened in the public sector. When we started working in the public sector, the amount of work we could do skyrocketed. So, we went from a couple hundred thousand patients per year to three million within ten years. We also expanded very rapidly across the country from the Dominican border and this has been a shift made ten years ago that we’ve tried to make sure our Africa work was all along those lines.

There’s two reasons to do that to work in the public sector as an NGO. One is scale. Everybody talks about scale. You’re not going to have scale if you don’t have a national framework or an administrative framework I should say. The other is if you really think at all about rights. Do we have any healthcare rights at all? And if so, who confers those rights? And the public sector confers rights for education and healthcare should confer water rights as well

Mary Kuntz: I am curious about funding. You said a few minutes ago that funding was still difficult. A lot has changed in the philanthropic world in the last 20 years with new kinds of organizations and bigger organizations, notably the Gates Foundation. Are you any more optimistic about the prospects of bringing treatment and care to regions that have been underserved? Has it gotten easier at all?

Paul Farmer: It has definitely gotten easier to find funding. The Gates Foundation by the way sort of did CPR on what used to be called international health. Back in the late ’90s before the Gates Foundation came into being, there were very limited resources being put into international health. And as a result, the experts at international health were always setting their sights lower and lower and lower.

Then a disease like AIDS comes along and it’s really not that easy to treat for those looking at everything in terms of the smallest amount of money that you can invest. So, you really had to have a paradigm shift and that happened. It didn’t happen at the end of the 20th century. It just happened in the last few years. Because then we followed with the President’s Emergency Plan for AIDS Relief and the Global Fund to fight AIDS, tuberculosis, and malaria and then that’s just a start. We need lots more mechanisms.

Mary Kuntz: Can you describe that paradigm shift? It sounds like it’s gone from containment to actual treatment.

Paul Farmer: That’s right. It’s gone from containment to actual treatment around AIDS. But, I would look at it in a somewhat different way. It’s gone from we have limited resources, we can only spend a very little bit, what do we do with this money to we’re going have to put in more resources if we want to be serious about altering survival for the people living in poverty.

So, I’ll give an example—a specific example. The vaccines that were developed in the earlier 20th century, they were like magic bullets. Measles vaccine prevents all cases of measles. So, you can have a fairly vertical program to deliver vaccines.

But, that’s not the way chronic disease is. It’s not that way with diabetes or AIDS and as I said if you work in a rural area, it’s very difficult and I think it’s wrong to have a vertical program. And the way it is for a doctor sitting in rural Africa for example is you can’t have someone with a broken arm come in and say, “Sorry, we don’t do broken arms. Go to the National Broken Arm Program.” Because there is no National Broken Arm Program. You can’t say, “We only do AIDS. Or we only do tuberculosis or women’s health.” So, that’s the kind of integration that we need to see happen to strengthen these health systems.

Mary Kuntz: I know you see your work as having a both a medical and a moral imperative. But, don’t wealthy nations also have a strong self interest in seeing your work succeed? To the extent plagues like HIV and TB are allowed to develop unchecked in poor communities? Does that put everyone at risk?

Paul Farmer: It does. I’ve got nothing against the self-interest argument at all. It’s just that that argument is so well enshrined in international relations that people are going to look out for themselves and powerful people and affluent people even more so. So, I think the moral imperative arguments are really trying to fill in a gap, in other words saying there are lots of other reasons besides self interest to do this. But, it is in my view definitely in the self interest of affluent nations to support this kind of work. It’s sort of we can, we need to, and by the way, we should.

Mary Kuntz: I’d like to talk a little bit about the can part of that. I know you split your time among some desperately poor regions as well as one of the world’s premiere hospitals in Boston—the Brigham and Women’s. So, you see in the course of your work, you see the best and the worst that medicine can offer. Is it a zero sum game? Can the world provide Brigham-type care for everyone? And should that be the goal?

Paul Farmer: First of all, I don’t think it’s a zero sum game. And I’ll tell you why. The care that gets delivered inside the Brigham is definitely the best I’ve seen. But, when our patients in Boston leave the Brigham and go home, their care is not so good. So, one of the things that we’ve said is we want to raise the standard of care in hospitals in Haiti and elsewhere in Latin America and Africa.

But, we also are going to take back some of the things that we’ve learned in those places. The more benighted places in the world and bring them back to improve chronic disease management in places like Boston. So, this community health worker model that I mentioned earlier—we brought it to Boston to serve people who were faring badly in the shadows of the great Harvard teaching hospitals. And, I got into a little bit of trouble with my coworkers when I said, “All we’re trying to do is raise Harvard levels of care up to Haiti levels.”

Mary Kuntz: The US spends more on healthcare by any measure than anyone else by a big margin. Is there waste in that number? Do we spend on procedures and care that’s not really effective and should that be redistributed somehow?

Paul Farmer: Yes, there’s an enormous amount of waste in American healthcare. If you look at some of the numbers, if you compare our country to other affluent democracies, you know that we don’t compare well. It costs more and it doesn’t deliver better care. But, the other point if we’re talking $6,000, $7,000 per person per year—we’re having to fight just to say that $40 per patient per year should be the minimum investment in rural Africa. We shouldn’t have to fight like that. I mean, we shouldn’t have to argue. We should have people saying, “Wow, you can do that for $40 per patient per year? Let us help.” I’m waiting for that to happen. I think it will.

Mary Kuntz: So what are the biggest obstacles that you face right now?

Paul Farmer: The Achilles Heel of this movement right now is still the same one I saw when I think it began ten years ago. And that is there is there’s a lot of interest on the part of universities and even teaching hospitals—a lot of interest on the American side. But, until we have strong support for actual delivery of services, what you might want to call an effecter arm.—an organization that can procure medications, hire and train the health workers, etcetera—until we work that out, we’re really risking sending our trainees away to some place where there isn’t adequate health infrastructure and there aren’t enough tools. It’s always a risk that you’d have people being spectators to poverty instead of being workers in the vineyard.

That has been hard because I wouldn’t want to send one of my trainees, let’s say a resident in obstetrics. I wouldn’t want to send her to a place where when someone comes along in obstructed labor—that is a woman having a baby, but unable to deliver. I wouldn’t want her to say, “Gee, I know exactly what to do. But, I don’t have the tools of the trade.” Therefore, the woman dies, and the baby. So, that’s fixable. We can fix that. And unfortunately, the institutions I’m most familiar with like—university—American university—they don’t have a history of supporting, a strong history of supporting building infrastructure, and supplying materials in far off places.

Mary Kuntz: Should that be the role of universities?

Paul Farmer: Well, you know, this is the response when I say this to universities. That’s not our role. Our role is teaching and research. And I’m saying, “Okay, but, then you can’t go to rural Africa because they’re not asking us to teach about them and do research on them. We have to actually find a way—have partners—who can help us do this in an ethical manner.”

Mary Kuntz: Any other obstacles?

Paul Farmer: For those of us working in the field, in a place like rural Africa, rural Rwanda, what we see, what I see, in that case is that tools that should be helpful like cost effectiveness or sustainability instead get transformed almost into weapons against excellence. Cost effectiveness analysis has become the primary tool by which an intervention is judged yay-or nay-worthy. The example from just eight or nine years ago and it’s still out there is, it’s not cost effective to treat AIDS in resource- poor settings. So, we have to prevent it. And that is such a scientifically fallacious argument. How do you know that prevention and care aren’t mutually reinforcing? How do you know what the cost of not treating are? Have you factored in all the AIDS orphans? Have you factored in all the cases of tuberculosis that will be transmitted by people living with HIV and dying from HIV? And, have you calculated in the cost to society when there’s no mothers to care for their children and this whole generation gets wiped out?

Mary Kuntz: Finally, how has your role changed?

Paul Farmer: I’m doing different things now than 15 years ago or even five years ago. I’m spending a lot of my time moving between these big infrastructure projects like building a hospital somewhere or several at once and also thinking a lot about how to cultivate the next generation of leadership in global health. That requires thinking about how to train physicians and nurses, how to expose medical students and even undergraduates to critical perspectives on global health. How to change policy—how to change policy in Washington especially since I’m an American. So, I’m doing a lot more. I’ll give an example. If you have a substantial fraction of America’s medical students interested in global health and you have huge amounts of tax dollars—US tax dollars going into global health and you don’t have any formal training program supported by the federal government, then clearly that’s a part of the puzzle that has to be shaped and put in its place.

Mary Kuntz: And do you see enthusiasm for that amongst students?

Paul Farmer: Oh, yes. I went to Harvard in 1984 as a student. We would have meetings—we used to call it international health back then. And maybe one or two people would show up. Now, half the class shows up. And that’s not just Harvard. That’s across the country. I don’t know about Europe. But, I can tell you in the United States, it’s a hot topic. Even to undergraduates. It’s a sea change, and, of course it’s very gratifying to me because this kind of work takes teams of people. And it’s not about individuals and no matter how hard working. It’s about teams of people and systems approaches. And in order to see it flourish, you’re going to have that new generation of people, willing and able to do the work. And they’re there.

Mary Kuntz: Well, it will be interesting to talk again in a few years to see how that new generation is doing. Paul, thank you very much for joining us today.

Paul Farmer: My pleasure, my pleasure.

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