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If you like Paul Farmer's story, you might also like:
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Benjamin Carson,
Francis Collins,
Denton Cooley,
Millard Fuller,
David Ho,
Willem Kolff,
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Linus Pauling,
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Richard Schultes

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Paul Farmer
Paul Farmer
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Paul Farmer Interview (page: 5 / 9)

Founder, Partners in Health

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  Paul Farmer

Do you see every pediatric death in Haiti as a failure?

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Paul Farmer: Well, sure. It's somebody's failure, right? What's the normal lifespan of the human right now? Say 80 years old. When I say normal, I meant if you have those things that one needs, like clean water, and vaccination against preventable illnesses, and education, and you're not caught up in some dreadful conflict. Why shouldn't you see grandchildren, right? That would be the normal course of human events if you have those things. So do I see every Haitian pediatric death as a failure? It's somebody's failure, usually, right? Same in Burundi or India or Cincinnati or wherever. I don't think it's a bad thing to see failure as failure, but it's important to understand how to assess causality. I know in some ways it's better to keep it simple, but claims of causality are really difficult to make. They are seldom buttressed by really sound data. If you say, "a" causes "b," then you ought to know how causality is created. For example, there are papers that ask, "Why do poor people behave poorly?" It's really a talk about causality. What drives behavior? Here we are in Southern Africa. We're talking about epidemic diseases here, but they're really caused a lot by labor migration. People don't talk very much about labor migration. Public health people don't talk about it very much, because they're not trained to talk about it. Medical people even less so, because they've had even less training. What I'm saying, and this sounds kind of wonkish, is large-scale social forces determine a lot of these things, including pediatric deaths.

So when I say, "Yeah, sure," it sounds dramatic to say, "Every pediatric death in Haiti is a failure." But it's true. Somewhere along the line, there's a failure. How else will we explain it? If you go to a place where infant mortality is, let's say, 150 per 1000 -- 150 children die in their first year of life -- there's got to be failures. So what are they? Well, they're a failure to vaccinate. They're a failure to make sure people have clean water, et cetera. So I think it's really a good thing to -- not so much assign blame -- but to assess why things are failing. It's also a good thing to take responsibility for that. So I don't see it as my personal failing when some kid dies in Oakland or Okinawa, but it is a failure. And I think it's probably better to think of it as our failure, not because we're into sack cloth and ashes, but because we're trying to fix fixable problems. So it's really, ultimately, a very optimistic thing to say, "It is a failure." I've thought a lot about this over the years, optimism and pessimism. When you say, "Hey, that's a failure," it's ultimately an optimistic kind of engagement, because you're saying, "That could be fixed." But if you say, "That's the way the world is," or "That's life," or "That's destiny," well, that's not so instructive in terms of having an action plan.

Students who want to go into public service or healthcare, or who want to serve in rural Haiti or Rwanda, might think they need degrees in medicine, cell biology, infectious diseases, foreign affairs or international policy. But how can business majors be useful in a service sector?

Paul Farmer: I think that's a great question.

There's another widespread misperception here, is that in order to be involved in these kind of problems, you have to take certain kinds of training. That's just not true, because as we said at the outset, we have all of this array of social problems. But let me just go back to business majors, for example. First of all, the problem is very often delivery, right? Let me put it in the most general terms. Do we have a vaccine for polio? Yes. Is it effective? Completely, or pretty much completely. So why do we still have polio in the world? 'Cause we haven't gotten the delivery down, and sometimes in speaking about these problems, you can talk about, "Discovery, Development and Deliveries." So discovery is something that happens in the lab, right? Often, and the polio vaccine comes from basic science research. And development -- you develop a product -- that can be done lots of different ways. Pharmaceutical companies develop products, for example. It's the third "D." It's delivery -- the implementation -- that is the biggest problem. And not to single out any company -- I don't really know much about companies -- but FedEx has to deliver their -- they have to get the thing there. And I think we need to take a similar approach to global health and development as, "We've got to deliver." We have to have ways of assessing how effective we are at delivering.

You mentioned business school and you mentioned business. There are clearly skill sets from the business sector that are important in public health and public good in general, like education, clean water. A very "big tent" approach is what we need for these problems. They're complex social problems, they have complex social answers, but we're going to have to have a very big tent. We're going to need those cell biologists and other basic science researchers to develop the tools. We talked a little bit about tuberculosis, but one of the biggest problems with tuberculosis is we don't have diagnostics. We don't have the tools we need to diagnose the disease. We don't have a vaccine, so these are basic science questions as well. So we have to do that, and then we have to develop these tools so they're available. Finally, and this is what I work on in a lot of Partners In Health projects, we work on the delivery side, taking these innovations in science and public health and delivering them.

They say doctors make the worst patients. Yourself included? What have you learned from getting sick yourself?

Paul Farmer: Drink clean water. I tell all my students that. Drink clean water.

Have you ever gotten so tired of system failures and losing patients that you lost hope?

Paul Farmer: No, I have not. But that's because I work with thousands of people. If you ever make the mistake of thinking that you're going to do something on your own, then you will learn the hard way that that's never the case. Maybe if you're a painter or a poet or an artist or a writer, but work in public health -- and public education and public good -- requires teams. Teams have to shore each other up. That's an important part of this work. You've got to work as a member of a team.

Do you remember any setbacks along the way that turned out to be invaluable learning experiences?

Paul Farmer: Yeah. For example, to lose a couple million people every year to tuberculosis.

But then there's this question, as I said earlier, "How do you assess failure?" How do you understand why a treatable disease becomes so lethal? And understanding that, in my view, requires lots of talking to patients, their families, the health providers, et cetera. And some of the things that we saw in the '80s, really, they were failures, because patients died. But they allowed us to diagnose the systems' problems and say, "This is where we need a community health worker system. This is where we need to make sure patients have food support while they're getting these medicines," et cetera. So those are examples of tragedies that certainly lead to -- not just personal epiphanies -- but collective epiphanies, where you say, "You know what? We can do this better if we have the system fixed."

You've spent so much time with the poor and the suffering in Haiti. Do you find a different paradigm in Haiti than you do in Peru or in Russia?

Paul Farmer: They're all different paradigms. New Jersey versus Peru versus Haiti. So everywhere humans hang out and develop cosmology, ways of explaining the world, there's always different ways of explaining misfortune, right? So yes, always different. But one of my questions is, "How much time do we spend looking at that, when we could address system failures and rebuild better systems?"

Do the system failures present similar paradigms?

Paul Farmer: Yes. The system failures require similar paradigms. The explanatory models vary enormously. So in Russia and in Rwanda -- which have no similarities -- or in Boston, the system failures are that we don't have a good enough community-based support for adherence. Those are system failures. But people's explanations of their suffering varies. It's all over the map.

Why were Haitian women working as servants in Port-au-Prince more at risk for contracting AIDS than women who stay on the Central Plateau?

Paul Farmer: I mentioned labor migration already, and this has happened all over the world with urbanization. Stable social networks, like families, get disrupted, right? I keep referring to South Africa, because we're in it, but that's what Cry the Beloved Country is about. That's happening all over the world. You look at the 19th century, and there were lots of rural communities that had their own kind of stability, and those were disrupted by urbanization and industrialization, and there's a lot of social pathologies with that. Now humans have to ask, "Is it worth it, the technological progress and advances?" I guess the answer is yes. That's why people are voting with their feet and moving into cities all over the world. But there are consequences, and that's why we have written a lot about gender inequality and poverty, and how they work together to increase risk for certain pathogens like HIV. I know that's a kind of longish answer, but it takes a long time to describe that.

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This page last revised on Sep 28, 2009 20:07 EST
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