Episode #5: Paul Farmer Fights for Global Health Equity

Chelsea Clinton: Hi. I’m Chelsea Clinton. Welcome to Why Am I Telling You This, the Clinton Foundation podcast. In many ways our world has never been healthier. Globally, people are living longer lives and child mortality rates are down. But one million children still die on their first day of life, and one million more in their first month. We know good, equitable primary healthcare and adequate disaster preparedness and response would help save newborn child and adult lives. My guest today, Paul Farmer, has spent his career trying to build health systems that can do just that. He’s a singular and inspiring figure in the field of public health. Paul is one of the most remarkable individuals I’ve ever known. Through his tireless advocacy and work with an organization he founded, Partners in Health, he has transformed health systems in some of the poorest places on Earth.

Speaker 2: In 1987, Ophelia Dahl, Paul Farmer, and fellow Harvard Med student, Jim Kim, established Partners In Health. They had no funds, but high ambitions to bring healthcare to the needy. Paul Farmer has worked tirelessly to treat individuals while spreading the medical gospel of healthcare for all.

Speaker 3: Since 1994, Rwanda has made progress in reducing extreme poverty. Healthcare has gotten special attention with the help of a Boston-based organization.

Speaker 4: For the first time patients in a public hospital are able to receive chemotherapy. For now, the expensive drugs are paid for by Partners in Health.

Chelsea Clinton: Throughout his career, Paul has worked to build basic health infrastructure around the world. I came to know him 20 years ago when I was a student at Stanford. And he’s been a friend and mentor to me ever since. I’ve had the privilege of working closely with Paul and Partners in Health in Haiti, Rwanda, and other places around the world through their partnerships with the Clinton Foundation. In each of our projects together, Paul has brought extraordinary scientific expertise, a commitment to working with local communities toward their specific goals, and a relentless focus on making good policies and seeing them through to implementation. Also importantly, Paul is a lifelong teacher who has been outspoken in his belief that everyone has an obligation to help narrow, and eventually erase, the health divide between the world’s rich and poor.

Why am I telling you this? Because at a time when global health crises and health systems are competing for headlines in an increasingly crowded breaking news cycle, it is more important than ever that we continue to pay attention to these urgent issues. Because efficient and equitable health systems not only save lives, they also break the link between sickness and poverty that keeps millions and billions of people at risk across the world. And, because we know that while the world continues to face multiple health challenges, we know that many of those are solvable, in part because of what Paul and Partners in Health have proven over time.

So thank you, Paul, for being here today. I want to start a little bit at the beginning, just as a starting point to explain why you started Partners in Health before we even had the kind of words global health equity, because that’s really what you were doing more than 30 years ago.

Paul Farmer: Of course I didn’t know those three words and how to string them together back then. As an undergraduate at Duke, the first time I thought maybe I don’t want to be a biochemistry major, which I was and enjoyed, was in a class called medical anthropology. And I only took it because it had the M-word in it. And it was the kind of course where you were expected to do a research paper, which sounded cool to me. And I did mine in the emergency room at Duke University. I was focusing this question on race and class and insurance status. So I learned a lot, because here was this big medical center, and African-Americans without insurance were using it as a primary care delivery system because they didn’t have another choice. And the history of Jim Crow and the segregation of hospitals and emergency rooms, even in 1980, lay heavily, or perhaps you would say lies heavily, on our country.

Chelsea Clinton: Absolutely.

Paul Farmer: Here’s people coming in who don’t have an emergency, and they’re coming into a university medical center emergency room. Why? Because the safety net would not otherwise catch them. Maybe it was that preparation in the United States, which of course I knew to be a land of bounty, and I actually-

Chelsea Clinton: Bounty hoarded and not equally distributed or accessible.

Paul Farmer: Exactly. So I had that understanding, or at least the awareness that inequalities were local and global. I had that early on. And even though a lot of my interpretations proved to be incorrect, a lot of my understandings were just wrong, ideas were flat out ridiculous, the basic conviction that people ought to have some kind of safety net, that proved correct. And it’s been a torturous path since then, but that’s what lead to Partners In Health certainly.

Chelsea Clinton: And Paul, even though you may not have had the words global health equity, can you just talk a little bit about how Partners In Health took the form it did and kind of why you focused so much on not only the delivery of care, but also the training of health workers and ensuring that Haitians were always at the center of what was being conceived, done, evaluated?

Paul Farmer: Some of this is such a given for us. For example, that Haitians would be at the center of an endeavor to promote what we later call global health equity.

Chelsea Clinton: And yet that’s not the way much of the world operates.

Paul Farmer: No, it is not.

Chelsea Clinton: It’s one of the priorities that’s always been so kind of crucially shared and important to us as people, but also between kind of all that we’ve done, the Clinton Foundation and the Clinton Health Access Initiative, and clearly that you’ve done and helped kind of pioneer through Partners In Health. And yet even though that seems so obvious to us, it still remains kind of not the expectation of global NGOs around the world.

Paul Farmer: And of course I’m not allowed to forget that because we bump into many and try to work with many as well who don’t have that as their central guiding principle. But global health equity is always going to be a way that can steer us towards that universality. It has to be about quality, dignity, respect, these more ineffable, but still measurable, ways of looking at how well we do thinking about equity. And that’s another reason, to get back to your point, to think very hard about making sure we allow our partners, let’s say the rural Haitians or urban Haitians or whatever, to be involved in the work as agents of change. And that requires thinking about, well, who gets to go to a university? Who gets to go to nursing school? Who gets to go to do a PhD in health policy? Whatever it may be. Who gets to be an elected official? The list goes on and on.

Paul Farmer: If you want to attack poverty, then you better make sure people living in poverty at the center of it. That was clear from that first year, although much was not. The understanding that people need to be the agents whenever possible of their own liberation from these shackles, I got that in year one.

Chelsea Clinton: What started in 1983 is largely providing basic medical care and then developed intro providing slightly more sophisticated medical care with medicines that you and Jim and others would bring in your suitcase from Boston to Haiti.

Paul Farmer: Great procurement plan.

Chelsea Clinton: Well, certainly better than nothing.

Paul Farmer: Yeah, barely.

Chelsea Clinton: And yet today, there are incredibly sophisticated procurement plans, logistics, infrastructure underneath all of what Partners In Health does. And you’re delivering tertiary care. You’re able to treat people in Haiti as well as you’re able to treat people in Boston. Can you just talk about the journey from 1983 to now.

Paul Farmer: I would love to. In those early years, of course we were full… I think we were full of passion and enthusiasm, and we have just as much or more now. But some of the things I would later learn in working with the Foundation for example were not at all clear. And one of them is what’s the big picture of how the work should look? There was already a lot of aid money, but the impact of that aid, say from the United States, was pretty negligible if you were showing up in central Haiti. I could see that. It didn’t have to go to the squatters settlement of Cange just be in [inaudible 00:09:09], which was on paper supposed to be a place where very substantial amounts of US aid were going there. But in 1983, there was little in the way of either primary or secondary or tertiary system. So if you had obstructed labor and you go to a hospital that has no blood bank and no obstetrician and no operating theater-

Chelsea Clinton: It’s not really a hospital.

Paul Farmer: It’s not really a hospital. It’s just not a hospital. And, again, I could see that at the time. We could say, “Is there a way for us to assess the main problems here?” And the first team that we had said, “Let’s go to every household, ask people what’s going on there,” meaning, find out who has access to family planning, which kids have been vaccinated, how many people live in the household. We weren’t trying to do an epidemiological study, we were just trying to say, “What are the ranking problems here? Could we find out?” And then the community health workers were called CHVs, community health volunteers. And it’s hard to be a volunteer if you’ve got six kids and other things to do.

Chelsea Clinton: And you’re not being paid for your work.

Paul Farmer: You’re not being paid for your work. Again, the dignity conferred by work really it was obvious even to a 23-year-old. That meant that as we were working with Haitians as our MO, including young Haitians our age, bad things would happen to some of them. The initial team based in Cange, there were six Haitians our age. And by the time I graduated from medical school, three had died. I had never had friends who died. Even though I came from a family without a lot of means, I didn’t know anybody who’d died. But these were my friends and they were my age. And it was the first time, and one after another. I was totally grief-stricken when the first of them… The first of them died, she was 27. I was probably about the same age. And she died just after childbirth. And then right after that, another young man, we mentioned water, well, what’s the cost of not having a clean water supply? Well, for babies, gastroenteritis, but for a healthy, robust, young guy, watch for typhoid. And one of the complications is it bores right through your intestines. And I would later become an infectious disease doctor, but you didn’t need to be an infectious disease doctor to think, “Wow, not only is that an outrageous tragedy, he was a good friend.”

These are things, by the way, that not only would have been prevented by having a tertiary hospital, that is, the illnesses would not have led to death. So, you have a baby, you get an infection, if you have a good hospital you’re not going to die from it. You have typhoid, you’re not going to have a perforated bowel because you’ll get antibiotics, and if you needed to, you’d go to the operating room. He actually died right outside the operating room, but this is in Port-au-Prince, and he was so frightened. And I was going back to medical school. I wasn’t a doctor. I was just with him. I’m like, “Oh my god, he couldn’t die, could he?” Well, I knew he could die, but he’s not going to die. He did.

And then the other young woman had cerebral malaria. And I’m not the only one who knew them well. I may have known them the best of the founders. But we all knew them all. And of course our Haitian colleagues, it was devastating, especially knowing that yeah, the illnesses should have been prevented, but after someone gets sick, you can also prevent death. That’s why you need a medical care delivery system. There’s no vaccine for malaria yet. The vaccine for typhoid is not very good. And there’s no vaccine for this infection after childbirth except for family planning. So on every one of those levels, prevention and care, we failed. We failed our friends.To say that it made me feel bad or guilty, it did. But it also was my first real experience with grief. And the stakes were already clear to us, and we already thought of this as a health equity issue.

So to get from there, again the first decade being mostly errors and full of these kind of tragedies, but not without joy and again, these friendships, it took a long time for us to admit, and the us here being our Haitian colleagues as well, that the work we were doing wasn’t really very good. It couldn’t be good because it wasn’t building up the Haitian healthcare system. It wasn’t providing comprehensive care. And we came by that knowledge the hard way. And wherever there’s a clinical desert, that is, you don’t have the staff you need and the stuff you need and the space you need-

Chelsea Clinton: And the systems.

Paul Farmer: And the systems.

Chelsea Clinton: You can’t forget your fourth S.

Paul Farmer: This global health equity, one reason we keep going back to that list, staff, space, systems, is because are there guiding principles that could lead us forward in varied settings. And the answer I think is yes.

Chelsea Clinton: I think you’ve proven the answer is yes.

Paul Farmer: You should be saying all of them. You should be saying staff, and it would be local staff, nurses, doctors, managers, community health workers, everyone who you would need to actually delivery care. So the stuff, I’m talking about medical supplies, medications, you have preventives, vaccines, you have diagnostics, how do you know if someone has HIV, what’s their viral load, how do you know someone has leukemia, a lab that can diagnose and identify the cancer. So staff, stuff, space, then it should be dignified space. Nobody wants to go to a hospital to have a baby when it’s dirty in addition to all the user fees and other obstacles, geographic ones, whatever. If it’s dirty and smells bad, who would want to go there for anything? So that dignified space is important. And then the systems. I’ll just say it, I keep learning about that. And I’m not done learning about any of them. But not having a healthcare system, a safety net, well, that’s what I saw as an undergraduate when African-Americans in Durham County were going to a giant university medical center for a basic primary care problem. So the safety net is composed of staff, stuff, space, and systems. But it’s only a safety net if it catches you if you fall.

Chelsea Clinton: You and I spend so much time thinking about kind of what can we try to improve, support, empower, kind of through medical care and also kind of more robust public health systems. And yet so much of what determines whether or not people are healthy happens even beyond those kind of large categories. How do you think about any of us who care so intensely about improving health outcomes and health equity, what do you think our responsibility is to not just be informed but try to be thoughtfully engaged in these larger debates of social and civic determinants of health?

Paul Farmer: The first discussion of social determinants ought to be well, there are social determinants. You can work really hard inside the walls of a clinic or on drug pricing or working with a ministry on the care delivery system, and you’re not getting at the major determinants of who lives, who dies, how inequalities get in the body. Those inequalities can be around race, class, gender, and are, by the way, but also rurality, what zip code you’re born in. That’s our daily bread. One of the anxieties that I have is there is a strain inside public health which is a Luddite strain, and I’ve seen it, we’ve both seen it again and again and again, where someone said, “Well, if poverty’s the chief determinant of health outcomes, then maybe we should focus all of our attention on poverty reduction and worry less about, let’s say, trauma care.” Well, that would not have been a good thing for me in 1988 when I walked in front of a car. Or, well, you should really focus all your attention on prevention. Well, how do you prevent breast cancer or leukemia? I don’t know. I managed to get hit by a car, and I couldn’t walk unassisted for six months after that. But I knew that the emergency medical technicians were not going to lean over me and say, “You should have looked both ways before you crossed the street, sorry.”

Paul Farmer: That’s what it is for a lot of people who don’t have that safety net and there are no tertiary care hospitals. I would hate to have the world suddenly illiterate in social determinants and forget about equity in care delivery. And we’ve seen it again and again. And I think there’s got to be a way for us to keep global health equity front and center because that would allow us after all to acknowledge that the quality of care matters, geographic distribution matters, access matters, and you have to have that safety net.

Chelsea Clinton: In the 35 years, more than 35 years now since Partners in Health was started, can you talk about how the work’s evolved?

Paul Farmer: I wish we were moving faster. But it’s so encouraging if you just stick with this for… I was about to say if you just stick with this for a few decades, it’s not a long time. What we’ve seen in Rwanda, to go from the bottom, the pits, Hell, which endured even after the genocide because even when there was better leadership, it still doesn’t mean you have staff, stuff, space, and systems. But to go there and to see what it’s like now, this is not a long time, and just what we have seen with our own eyes…

Chelsea Clinton: Think about Butaro.

Paul Farmer: A place like Butaro, the district of Burera, the last one without a district hospital, first of all, you remember those first visits, beautiful.

Chelsea Clinton: The red dirt, the mountains.

Speaker 6: Rwanda’s most modern hospital was built in Butaro in the mountainous north mostly with funds from Partners in Health.

Paul Farmer: This big hospital, on top of this hill, mountain, is related to a series of health centers and to people working in the villages. This is a district of over 400,000 souls, and in 2003, 2004 there was not a single doctor, much less a district hospital.

Speaker 7: Just as I was about to start my final exams, I decided to take a break from an all-nighter and go to a lecture by Dr. Paul Farmer, a leading health activist for the global poor. And I was surprised to hear a doctor talking about architecture. “Where are the architects?” Paul said. “If hospitals are making people sicker, where are the architects and designers to help us build and design hospitals that allow us to heal?” For the next year I’d be living in Butaro in this old guest house, which was a jail after the genocide. And I was there to design and build a new type of hospital with Dr. Farmer and his team.

Paul Farmer: Some people, they’re startled, some of the Rwandans are startled. I’ve had Rwandans come here and say, “Is this a resort? Is it a hotel for Mzumbus? Is it for foreigners?” And be skeptical when we respond, “No, this is for you. This is your community hospital, your district hospital.”

Speaker 8: As a result, the number of children dying before age five has dropped to a quarter of what it was in the year 2000. The number of mothers who die in childbirth is down 66% since 1990. In part because 99% of pregnant women receive at least one prenatal care visit.

Paul Farmer: People say, “Well, how do you do this work around people who are so ill and suffering? Why isn’t that depressing?” I can’t think of anything less depressing than being able to see that kind of progress in so short a time.

Chelsea Clinton: I do, though, kind of want to end with asking you not if you’re optimistic, because I know you are, but why you’re optimistic and what are you most optimistic about? Because while we have seen such tremendous progress, massive decline in under-five mortality over the last 25 years, we still have a million children who die on their first day of life and a million more who die in their first month of life, and we still have millions of kids who die every year from things that are not only preventable if they were to be fully vaccinated, but also preventable if they knew how to swim or if there were good roads or if there were seat-belts. And yet, I know that you are optimistic.

Paul Farmer: I am.

Chelsea Clinton: So, why are you optimistic? And why do you think anyone should be when we think about global health equity?

Paul Farmer: There’s a lot of really wonderful people who we meet who are drawn to global health equity. And that’s a cause for optimism. Yeah, there are setbacks. We didn’t even talk about the earthquake. That was a dreadful experience. And that’s probably why you didn’t bring it up. I still don’t like talking about it.

Chelsea Clinton: I know.

Paul Farmer: But when I see all the people who got involved… Your mother told me that more than half of all American households contributed to earthquake relief in Haiti. And to know that that many people cared about the distant stranger suffering they wouldn’t see directly, that’s not even counting the people who showed up, how could you not say, “Well, we’re redeemable as a species yet.” But one of the things I’d like to get out in this exchange is as just a way of encouraging others, if you get involved in it and you stick with it, wherever the it is, you’re going to see massive progress. Sometimes it’s really dramatic and fast, and I would say Rwanda is the best example we know. What’s happened there in the last 15 years in terms of just looking at the basic measures, infant mortality, child mortality-

Chelsea Clinton: Maternal mortality.

Paul Farmer: Maternal mortality, or around AIDS, tuberculosis, malaria, whatever, those are the steepest declines in mortality ever documented-

Chelsea Clinton: In history.

Paul Farmer: In history. And to know that that could happen there, how could you not be optimistic? I think we are maybe getting that message out more, but this pessimistic view of the world is wrong, and of course cynicism is wrong. Cynicism is a dead end.

Chelsea Clinton: That nothing can ever change.

Paul Farmer: Nothing can ever change, and that’s just ridiculous. But I think that our optimism is warranted.

Chelsea Clinton: Well, I agree.

Paul Farmer: And I love this work.

Chelsea Clinton: And Paul, thank you, you make me optimistic every day. And I’m so grateful for you in the world and for your time for our conversation today. So thank you very much.

Paul Farmer: I hope I’m allowed to come back.

Chelsea Clinton: Anytime.

Paul Farmer: I’ve got a lot of podcasts in me even though this is only my second.

Chelsea Clinton: Anytime, Paul, anytime.

Kevin Thurm: Hi, I’m Kevin Thurm, Chief Executive Officer at the Clinton Foundation. Building on a lifetime of public service, President Clinton established the Clinton Foundation on the simple belief that everyone deserves a chance to succeed, everyone has a responsibility to act, and we all do better when we work together.

From our programs that are creating economic opportunities, improving public health, and inspiring civic engagement across the country and around the world – we’re putting people first.

Thanks for listening to Why Am I Telling You This?. To learn more about how we’re helping people across America and around the world, head to Clinton— Foundation—dot—org— forward slash— podcast.

Chelsea Clinton: Next on Why Am I Telling You This?

President Clinton: Today, I’m joined by one of the athletes who won gold in those ’96 Summer Games, Dawn Staley. Tell me about the Olympics, how did it affect your life? How is it different from all the other contests you were in?

Dawn Staley: Wow, the Olympic games. Growing up in the projects, I only saw women play two times on television. One was the NCAA Women’s Final Four and the other was the Summer Olympic Games and I wanted to do both. I wanted to be a national champion and I wanted to be a gold medalist and playing for USA basketball is basketball utopia. The Olympic games and the USA basketball experience is what I model my coaching after.