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Paul Farmer: "We've Met the Enemy and He Is Us

By Michael Igoe
December 15, 2014

(Click here to view the original article.)

Paul Farmer is not an easy man to track down.

The U.S. physician and medical anthropologist — who came to be known as “the man who would cure the world” after the award-winning book “Mountains Beyond Mountains” detailed his quest to treat tuberculosis patients in rural, low-income areas — is famously tenacious.

His energy and expertise are in high demand and have taken him to many of the world’s health crisis hot spots, to its forgotten underserved corners and to its centers of political power. Devex caught up with Farmer last week at the U.S. Senate, where he offered his assessment of key lessons learned from the Ebola outbreak in West Africa to the Foreign Relations Committee.

Farmer pressed senators and Liberian President Ellen Johnson Sirleaf — who tuned into the hearing via webcast — on the need to address the global health system’s “human resources crisis,” which Ebola has unveiled in deadly resolution.

After the hearing, Farmer spoke with every attendee who approached him, from senators to ambassadors to young professionals.

Whether or not he qualifies as a celebrity, the global development luminary gives no impression of having sought the distinction. Instead, his confident observations and credibility earned through a drive to witness and treat lent a kind of ready-for-action gravitas to the fleece vest he wore — emblazoned with the insignia of Partners in Health, the global nonprofit Farmer co-founded with World Bank President Jim Yong Kim — to testify inside the Senate chambers.

One of Farmer’s conclusions for the Senate panel was that the aid community’s commitment to “building local capacity” has often been “distorted.” Devex pressed Farmer on the point after the hearing — and after his cue of admirers dissipated — to hear what changes he would like to see to the way ideas like “capacity building” get translated into action — and funding.

Here is an excerpt from our conversation.

What changes do you see could be made today, in terms of procurement or policy, to make that effort to “build local capacity” real?

It is your audience. It’s us, in other words. We’ve met the enemy, and he is us. We’re the ones asking for those resource and misdirecting them. We all know that that’s not how you train an infection-control nurse or a health manager, with a two-day workshop or a “training the trainers.”

What is standing in the way of delivering those kinds of substantive, credentialing trainings to health professionals in places like Liberia, Sierra Leone and Guinea?

It’s saying, look, some of our efforts, our passions, our resources, our money are being misdirected by this contractor model — here’s the beginning of the program, here’s the end, here’s our overhead and our administrative fee. That model is leading us away from the output, which is really well-trained — in the case of [the Ebola crisis] — health care providers, including doctors and nurses, supply chain experts.

There are no programs like that being funded. You can’t find any residency programs. How do we train doctors and nurses in the United States or Europe? We train them in residency programs. I don’t see any of our money going into that. It’s ridiculously hard to raise money. Even after the earthquake in Haiti — to build a teaching hospital when all the teaching hospitals have just been destroyed? Nope, the development community would say, “well that’s not a priority.” To fund residency programs? “Not our job.” That was a constant comment. It’s way too hard to do that kind of work.

Socialization for scarcity has us pitting one good thing against another — prevention versus treatment, nurses versus doctors, emergency response versus development. It’s a curious pathology that comes from us.

Is it tied into the notion that aid should be focused on whatever achieves the “biggest bang for the buck?”

Yeah, but why is that that focus? You could say that education should be focused on the biggest bang for the buck or corporate returns. It’s just a way of thinking. Who doesn’t want to be effective? Who doesn’t want to use their resources wisely? But what we’re adding on is we have really scarce resources. Let’s only do the things that will give us the biggest bang for the buck.

So why?

I’m just trying to stand back and say, why is our starting point always, we have scarce resources? Who said? What would we not give now to have intervened in between December and May? … If we’d done the things that we’ve advocated now — improved infection control, bring in staff, space, stuff, systems — you wouldn’t have a runaway epidemic. Now it’s gone from millions to hundreds of millions to billions just to turn it around, without even leaving a social safety net in the future.

The biggest bang for the buck, it’s a great idea, but it’s really a metaphor or a way of thinking [more] than a prescription. If it’s your mother who’s fallen sick with Ebola, you’re not going to buy into the argument — “well, you know, it’s really too late for her.” You’re going to do what’s happened to the Americans who made it back here. That’s why none of them has died. They got critical care.

You think it’s hard to fund a training program for doctors and nurses — a real one? Try funding an intensive care unit … even after an earthquake. You’ll get in [mobile army surgical hospital] units from the United States or Israel or some military, and then people leave, and there’s no more ICU. There’s no more surgical care.

By the way that’s what I was doing in Sierra Leone in June. I’d gone to a health systems meeting around surgery. … I was there and looking at what they had on hand in terms of infrastructure. … It was clear it was going to spiral out of control.

Isn’t the characteristic argument though is that those higher-level medical interventions are things that a state should be providing to its citizens?

Yeah, that is the argument, but how much is the state investing in health care? The Abuja Declaration [to increase public health funding in Africa], which was spawned by our people, Devex-type people … are Liberia, Sierra Leone and Guinea meeting those agreements? No.

If the state is not performing in this arena, why is that? That’s an important question. Look at the difference between Health for All by the year 2000 — the Alma Ata Declaration and the Bamako Initiative, which is, “let’s get the biggest bang for the buck with the tiny amount of money we have.” Those are mutually discrepant.

It’s great when the public sector is doing this. Can we really say, we can’t accompany the public sector to do this better? Of course we can. PIH works with the public sector. If they can’t build a major teaching hospital in 18 months after a major earthquake in Haiti, that doesn’t mean we can’t build one with and for them, and then be there long term. And that doesn’t take away from community health workers or economic development. It adds to it.

Who needs to drive this shift? Is it development implementers?

I think the socialization for scarcity is the primary pathology. We’re competing with each other instead of adding up to more than the sum of our parts. So part of it is a cultural change internally. It was only [after U.S.] President [George W.] Bush created PEPFAR … that it kind of unstick the thinking of the public health nihilists.

And there are treatment nihilists with Ebola too, [saying], “Forget it. They’re already sick. Let’s just focus everything on prevention.” How are you going to get people to rush into the hospitals and clinics to be isolated without care? You’ve got to link prevention to better care.

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