Accompaniment as Policy
Paul FarmerKennedy School of Government, Harvard University
(25 May 2011)
There's a biblical comment somewhere, probably in the Old Testament, which argues that "No one is a prophet in his own land." So I'm especially grateful for the invitation to deliver a commencement address here at Harvard, and even more so at the Kennedy School, where governance and policy are the focus of your studies. Although I'm a physician, and a teacher of physicians, this past couple of years has been an object lesson about the difficulties of moving from the care of individual patients to building health systems in settings of privation and disarray. This is precisely the arena I thought I knew most about—linking patient care to the strengthening of health systems—but the January, 2010, earthquake that ended so many Haitian lives and destroyed so much infrastructure taught us that we still do not possess the ability to translate good will and resources into robust responses to disasters natural and unnatural. And although I will reflect mostly on lessons learned in Haiti, I submit to you graduates that some of these lessons will prove useful in far less dramatically disrupted settings, including this city and this country.
Here, then, are three things learned and relearned over the past few years. All of them turn about the notion of accompaniment. It's an elastic term: it means just what you'd imagine, and more. To accompany someone is to go somewhere with him or her, to break bread together, to be present on a journey with a beginning and an end. At a commencement like this, we're not sure exactly where the beginning might be, and we're almost never sure about the end. There's an element of mystery, of openness, in accompaniment: I'll go with you and support you on your journey wherever it leads. I'll keep you company and share your fate for a while. And by "a while," I don't mean a little while. Accompaniment is much more often about sticking with a task until it's deemed completed by the person or people being accompanied, rather than by the accompagnateur.
I teach here at Harvard but volunteer with Partners In Health, an organization I co-founded over 25 years ago. We've sought to make accompaniment the cornerstone of our efforts, from rural Haiti to corners of Boston to the prisons of Siberia. In every setting in which we've worked, there are people who need accompaniment: patients with chronic disease, families facing loss or chronic troubles (most linked to poverty, like lack of shelter or food or schools), but also public health officials and clinicians without ready access to the tools of our trade. In other words, even the erstwhile accompagnateurs need accompaniment. It doesn't weaken the concept to note that everyone who draws breath needs accompaniment at some stage of life, and that some need more than others. Nor does it weaken the notion of accompaniment when we acknowledge, at the outset, that its role in policy formulation and in policy implementation will vary from place to place and time to time. There's no one-size-fits-all approach, but there are surely basic principles of accompaniment.
I first heard the term accompaniment somewhere between Haiti and Harvard. The year following my graduation from college, way back in 1982, I found myself in a squatter settlement in central Haiti. I've told this story many times, to my own students and to anyone who'll listen, but hope it bears repeating today. Why were those people gathered in rickety thatch huts on a dusty hilltop? Because they'd been displaced by a development project, a hydroelectric dam that flooded a fertile valley in order to improve agribusiness downstream and to send electricity to far-off Port-au-Prince. (The dam was built by a company later absorbed by a tiny concern named, I believe, Halliburton.)
Irrigation and electrification are worthy goals. But I was living among people who blamed their misfortune on an infrastructure project that was, at the time of its completion, one of the largest buttress dams in the world. This experience gave me a new view of official development projects—a dim view, to say the least, since the displaced received neither water nor electricity. It taught me a lot about what sociologists call the unanticipated consequences of social action.1
In 1984, as a first-year med student, I returned to Haiti often to work with community health workers; we had not yet recruited doctors or nurses, since we hadn't yet built a hospital. When community health workers confronted acute illness in their home village, they would refer patients to the new clinic, which a decade later became a small hospital and then a medical center. But we learned early that patients with chronic disease, from tuberculosis to diabetes, needed a lot more than the passing medical attention one receives within a clinical facility: they needed long-term social support. Even to get from their villages to the clinic required help with transportation and child-care; these families lived in deep poverty and first needed food and clean water and shelter to benefit from medical care.
For example, when we made financial and nutritional support central to our tuberculosis program, and trained community health workers to deliver care to afflicted neighbors, these changes in the system boosted cure rates as much as they did morale. You may have missed our paper in Seminars in Respiratory Infections twenty years ago, but I believe we introduced the term "donkey rental fee" to the health policy literature.2 And we took to calling such complex wraparound services "accompaniment"; the community health workers were of course the patients' accompagnateurs. Although we also used the term "directly observed therapy," which came from the public health literature on tuberculosis, accompaniment was meant to be more supportive than supervisory.
When AIDS later reached these villages, at the close of the Eighties, we accompanied people living with HIV and poverty, too. And our team took this same notion to Roxbury, Dorchester, Mattapan and elsewhere in Boston, since it was clear enough that people living in the shadows of Harvard's great teaching hospitals also needed accompaniment in their homes and neighborhoods; they also had trouble making appointments and finding childcare and keeping up on rent or other bills.3
It was ultimately a series of policy decisions, made years later, which infused new resources into the diagnosis and care of chronic illnesses, including AIDS and tuberculosis, in some of the poorest parts of the world. Some of these ideas were first discussed right here at the Kennedy School with the economist Jeffrey Sachs, who sometime at the close of the Nineties invited me to address a class here. I returned the favor by inviting Sachs to that same squatter settlement in central Haiti. Of course, it looked very different in 2000 than it had in 1983. The dust had been replaced by trees and green; there were schools and a hospital. There were hundreds of jobs. Lean-tos had been replaced by tin-roofed homes. It certainly wasn't perfect, and it was small, but it was immeasurably—or should I say measurably?—better than two decades previously.
Jeffrey and his wife Sonia, a pediatrician, had come to see what was, astoundingly enough, our "controversial" AIDS program. Why it might be controversial to treat AIDS in "resource-poor settings" is about a failure of imagination (the drugs were deemed too costly for "those people"). But Jeffrey, sympathetic to our efforts, had come to see for himself. He wasn't feeling well during that visit, and I, responsible doctor that I am, suggested that a brisk walk to a village about two hours away would do him good.
I almost killed Jeffrey Sachs. Five hours in the blazing sun did not, in fact, improve Professor Sachs's clinical status, but he did get to see community health workers—accompagnateurs—tending to patients with AIDS, patients who were doing just fine once they had access to the fruits of modern medicine.4 This was significant since AIDS had become, by that time, the world's leading infectious killer of young adults, but there was no available funding to link HIV prevention to proper care.
The history of the rise in funding over the past decade has yet to be written fully, but the Global Fund to Fight AIDS, Tuberculosis, and Malaria, an idea Sachs proposed some time ago, was a milestone in multilateral efforts to counter unnecessary suffering and death, as was the Bush administration's Emergency Plan for AIDS Relief (PEPFAR). These programs have their flaws, but they have penetrated political processes and influenced policy around the world.5 Yes, they are too "stovepiped," that is, limited in scope and not sufficiently coordinated with efforts to address maternal and child health and other problems endemic to the poorer reaches of the world; they remain underfunded. But they are worthy efforts nonetheless.
With the establishment of the Global Fund and PEPFAR, something else had happened: there was for the first time a precedent set for life-long accompaniment of people living in poverty and facing incurable but treatable diseases. Think about diabetes or mental illnesses, which are huge scourges in settings of poverty. We also hope that "health care reform" in the United States will lead to home-based accompaniment for chronic disease and to increased support for community health workers in this country.
Accompaniment is an elastic term, but not too elastic. It is not the same as a paid consultancy or a one-off project to help certain institutions or individuals for a little while. As noted, the beginning of accompaniment is often clearer than the end. There is a theological literature on accompaniment, and if you have the temerity to plumb it, you will be reminded of the term's Latin origins: ad cum panis, which is one way of saying breaking bread together.
The term crops up especially in liberation theology, which has its roots in Latin America, where Partners In Health also has its deepest roots. PIH is a secular organization, but that doesn't mean that those of us who make up a network of 13,000 people in 12 countries don't draw on inspiring work by people like Gustavo Gutiérrez, a Peruvian priest who has written so compellingly of "the preferential option for the poor."6 This became a guiding principle of our work: although everyone deserves decent medical care, those living in poverty were going to receive the lion's share of our attention. It was also true, as any epidemiologist could tell you, that diseases themselves make a grim and preferential option for the poor. It would be our life's work to accompany them on a journey away from premature suffering and death.
Of course these two notions—an option for the poor and accompaniment—were necessarily related. In an interesting book about a theology of accompaniment, Roberto Goizueta of Loyola University in Chicago, writes, "To 'opt for the poor' is thus to place ourselves there, to accompany the poor person in his or her life, death, and struggle for survival."7 Professor Goizueta, who draws heavily on the work of Father Gutierrez, is focused on the accompaniment of Latinos in this country, especially those in cities, and writes about the necessity of physical proximity to accompaniment: "As a society, we are happy to help and serve the poor, as long as we don't have to walk with them where they walk, that is, as long as we can minister to them from our safe enclosures. The poor can then remain passive objects of our actions, rather than friends, compañeros and compañeras with whom we interact. As long as we can be sure that we will not have to live with them, and thus have interpersonal relationships with them… we will try to help 'the poor'—but, again, only from a controllable, geographical distance."8
The distances are not only spatial but temporal. It may be possible to accompany those who have already suffered and died. The first class I taught at Harvard was as my mentor's teaching fellow. Arthur Kleinman and I taught a course we designed together, and called it, à la William James, "Varieties of Human Suffering." We showed Claude Lanzmann's film Shoah and I was recently reminded that, for the filmmaker, the most "profound" and "incomprehensible" part about the experience of making the film was a sense of accompanying "all those who died alone." In an essay called "Shoah as Shivah," the historian Michael Roth picks up on this point: "In accompanying these people, in passing with them through the past, Lanzmann performs what Jewish law calls a 'highly meritorious act.' He comes to dwell with those who suffer loss, and with some who are lost in their suffering. The absence is to be made present for the community of mourners through a ritual that brings the dead to mind, to voice."9
So what does this have to do with governance and enlightened policy? Let me draw on my experience responding to the earthquake that leveled much of Haiti's capital city a year and a half ago by comparing conventional "aid" to what an accompaniment approach might look like. There was an outpouring of humanitarian relief after the quake, and one of the jobs of the UN Office of the Special Envoy, namely President Clinton, was to track this aid and pledges for reconstruction. Here are some startling numbers, especially if you're interested in strengthening public health and public education: of the $2.4 billion disbursed, 34 percent was provided to donors' civil and military entities; 30 percent was provided to UN agencies and international NGOs; 29 percent was provided to other NGOs and private contractors; 6 percent was provided in-kind to unspecified recipients; and 1 percent was provided to the Haitian government.10
A couple of caveats: first, this was for direct relief, not reconstruction, for which we don't yet know the numbers. Second, it's hard to put resources through a government that lay in ruins: 28 of 29 federal buildings were damaged or destroyed, and perhaps 20 percent of federal employees were killed in the quake. And God knows we needed the logistic and medical support of outfits like the USNS Comfort, which steamed into Haitian waters on day eight after the quake. But surely more could be done to accompany local authorities who sought accompagnateurs for direct relief and reconstruction.
In Haiti, implementing the accompaniment approach would require new rules of the road for foreign assistance. If almost none of the direct relief money went to Haitian authorities, and very few of the reconstruction contracts are going to Haitian firms, where is it going? A lot of it goes to foreign contractors and international NGOs, which often have high overheads.11 Many of you graduating today will soon be leading such organizations, if you don't already, and you will need to help find a new way of accompanying our development partners. Sometimes this will include more direct budgetary support for struggling public health and education authorities, more support for local firms, and more local procurement. We are hoping to launch modest projects with some of the big development players, like UNICEF, to show, for example, how child survival projects can save kids' lives while also strengthening local capacity by creating jobs and by procuring more supplies locally.
It's been hammered home to you all: evaluation of such efforts is key. No one would dispute this. But what you have, while most of our beneficiaries do not, is ready access to "platforms for evaluation," ranging from spreadsheets to accountants to computers and electricity. Accompaniment will help put such platforms under the control of the intended beneficiaries.
Second point: the great failures of policy and governance usually occur because of failures of implementation, and accompaniment is good insurance against such failures. There are, of course, many bad policies; they've scarred the world in diverse ways and damage the vulnerable most of all. But most policies cooked up in places like the Kennedy School are not bad policies. Most policies developed by UN agencies or ministries of health are not bad policies. When NGOs take the trouble to develop policies, which isn't all that often, they are also not bad policies.
The problem is delivery.
Again, let's consider Haiti. A Haitian graduate of the Kennedy School, Jerry Tardieu, told me of a project called the "Haiti Caucus" going on here now: a challenge to come up with innovative policy projects that might help Haiti recover from the quake. A large number of students have already come up with an even larger number of great ideas. "They get it," he said, and I believe it.
But great ideas may abound, at Harvard and in Haiti, without any real plan for implementation. When Corail-Cesselesse, a windswept plain north of Port-au-Prince, was identified as a possible post-earthquake resettlement location, scores of architects and urban planners set to work developing plans by the dozens. But the months dragged on and still no one had broke ground. In fact, no one even bothered to check whether the proposed site was suitable for implementation. The tendency to "minister from safe enclosures" rather than from the place itself led planners to overlook the minor detail that Corail sat smack in the middle of a floodplain. Anything built there would have sunk in the mud during the rainy season.
The road from policy development to implementation is usually long and rocky, one that must be trod with companions. Two of mine are graduating here today. Both Alice Yang and Melissa Gillooly have been my accompagnateurs for many years, as I hope I've been theirs.
In my experience working with them prior to their studies at the Kennedy School, they had complementary skills. Alice was "The Scholbutt Queen"—able to ferret out the scholarly buttressing for the important work of documenting what it is we were trying to do in reaching from policy to implementation through accompaniment. She was my accompagnateur in research and critical reading and writing. I doubt I'd sport the title university professor without Alice, since careers are not advanced within academe without publication, and well thought-out and properly "scholbutted" publications at that.
Melissa, possessed of good cheer and great organizational skills, later became a master implementer herself, when she moved to Rwanda to manage Partners In Health's most ambitious effort in Africa. Her hard labors have been well rewarded, as she must be proud of what we've been able to do with the Rwandan Ministry of Health: build or rebuild three hospitals, over a dozen health centers, and serve perhaps a sixth of the population, growing a local partner organization almost as large as our Haitian operation in less than half the time. Melissa was the operations manager of this endeavor prior to her studies here. She accompanied thousands of colleagues, and through them, hundreds of thousands of patients.
The worlds Alice and Melissa span are often jarringly different from each other. A story of accompaniment will illustrate. About ten years ago, one of my colleagues was examining a patient, a five-year-old girl, and found a tumor in her abdomen. It was in fact a cancer on her right kidney, curable if removed before it spread elsewhere. That procedure, a nephrectomy, was performed in rural Haiti, because one of the things we did was to build a hospital in the aforementioned squatter settlement—an investment which was regarded by some policy experts as a foolish one. (Why build a hospital in a squatter settlement?) The procedure went smoothly enough, but an x-ray suggested that the cancer had already spread to her lungs, and she needed chemotherapy and radiation, which we could not do there. Since my family was then living in a faculty apartment in a Harvard dorm—our daughter Catherine was a little younger than this girl, whose name was Maveline—but often absent, we thought perhaps the child and her mother could stay there for the month or two she might need treatment in Boston.
The two months or so turned into a year, so I got pretty close to Maveline and her family. On the months that I was not in Haiti or Peru, but on service at the Brigham and Women's Hospital, I would come home from the hospital at about nine at night, tired but looking forward to seeing Maveline, especially when my own daughter was away. Maveline's mother, who had never been out of central Haiti before all this, would make me dinner and we would sit and watch cartoons or whatever Maveline wanted.
But there was a downside of living in a faculty apartment, and that was frequent student visitors. I thought it best not to complain about this, since these students also looked after Maveline and her mom, who were wholly unfamiliar with Cambridge. One night, well after nine, I was eating a home-cooked meal and sitting with Maveline and her mom, and there was a rap on the door. An expletive came to mind, but I suppressed it in front of the child; the word wouldn't have fit with the Teletubbies. When Maveline's mom opened the door, I saw two students: one from Harvard and a Haitian student from MIT. The Harvard student, Emilio, was from Miami, and though he had never once traveled to Haiti, he'd mastered Haitian Creole with a touching fluency that said a lot about him as a person (he has since become a Jesuit priest and has dedicated himself to the poor in Haiti and Brazil). The MIT student I'd never seen before, but the conversation—completely in Creole—went something like this:
MIT Student: "You're Dr. Paul Farmer?"
Me (Suppressed thought): "No I killed him and took his apartment." Actual words: "Yes, nice to meet you."
MIT Student: "You wrote The Uses of Haiti?"12
Emilio, somewhat proudly: "Yes, and he's written other books as well."
Maveline's mother, hands on hips, mildly offended: "Dr. Paul, you never told me you knew how to read and write!"
I tell this story to amuse you, sure, but to illustrate how inequality works in the modern world and what worlds accompaniment needs to span. Maveline is still alive and well, but I'm not confident her mother knows how to read and write.
Think of all the things Haiti needs and deserves—from proper cancer and surgical care to new and better health systems. But for these desired social outcomes to come to pass in Haiti, we will have to move from aid to accompaniment. Using Maveline as metaphor and example, we will need an open-ended commitment—her care did not last for a couple of months but for years. We will need to improve local infrastructure: if she'd been seen earlier, and her tumor found before it had spread to her lungs, much needless suffering would've been avoided. If her mother had been able to attend public school, chances are that Maveline might not have been born to poverty, since study after study shows that investing in girls' education is a great way to reduce poverty. And accompaniment is fundamentally integrative, since you wouldn't say, "Sorry, Maveline, we can help you with your surgery but not your chemo." If the biggest failures in the policy world concern implementation or delivery, the second biggest cause of failure regards integration of programs too often stovepiped, even though the problems they seek to address, from malignancies to illiteracy, occur in the same families and communities.
Third, the problem of integration brings me to my final point: beware failures of imagination. These are the really costly failures. Malcolm Gladwell quotes an engineer speaking of his former employer: "Xerox had been infested by a bunch of spreadsheet experts who thought you could decide every project based on metrics. Unfortunately, creativity wasn't on a metric."13 Neither are goodness or decency or social justice or patient accompaniment. But that doesn't mean we don't need these traits in public policy and in service for the common good. Just because we cannot yet measure the value of accompaniment doesn't mean it cannot serve as an important notion to guide us forward.
Another way of putting this: beware the iron cage. About 25 years ago, when I was a graduate student here in two different fields, medicine and anthropology, I went to buy an enormous book by the sociologist Max Weber. It hurt my back and brain to even look at this giant tome, but his topic—how the "iron cage" of rationality comes to suppress innovation—remains relevant to this day, as does his concept of "routinization." As programs and institutions grow, and as platforms of transparency and accountability are strengthened, the notion of accompaniment can be threatened, since it is, as noted, open-ended and egalitarian and elastic and nimble.14 For Weber, "Routinization is the process by which charismatic authority is succeeded by a bureaucracy controlled by a rationally established authority or by a combination of traditional and bureaucratic authority."
When the iron cage of rationality leads to an imaginative poverty, cynicism and disengagement follow.15 It's easy to be dismissive of accompaniment in a world in which arcane expertise is advanced as the answer to every problem. But expertise alone will not solve the difficult problems. This was the long, hard lesson of the earthquake: we all wanted to be saved by expertise, but we never were. True accompaniment does not privilege technical expertise above solidarity or compassion or a willingness to tackle what may seem to be insuperable challenges. It requires cooperation, openness, and teamwork of the sort Melissa and Alice and so many of you cherish. Much more can be accomplished, looking forward, with an open-source view of the world. Ideas for good governance, whether of organizations or government bureaucracies or corporations, are meant to be shared and shared widely. This is true of sectors public and private. As Bill Clinton notes in his book, Giving: "Many of the problems that bedevil both rich and poor nations in the modern world cannot be adequately addressed without more enlightened government policies, more competent and honest public administration, and more investment of tax dollars. There is plenty of evidence that more effective government can produce higher incomes, better living conditions, more social justice, and a cleaner environment across the board. But in many areas, regardless of the quality of government, a critical difference is being made by citizens working as individuals, in businesses, and through nongovernmental, nonprofit organizations."16
All of you gathered here today share an interest in public policy. This is true whether you're headed off to work in government (about a third of you, if my intel is good) or in the burgeoning non-government sector or philanthropy for public good or private consulting firms (a great deal of the other two thirds). You were admitted to the Kennedy school because you were already leaders, already accomplished, and deemed likely to make an even greater difference with skills and knowledge and ideas garnered here. I have no doubt that you will go forth and lead thoughtfully, but you are going into a world that spans the worlds I just described, which are of course really part of one world. May the idea of accompaniment go with you on your own journeys, wherever they may lead you.
Godspeed and thank you all.
1 See Merton R. The Unanticipated Consequences of Purposive Social Action, American Sociological Review 1, no. 6 (1936): 894-904.
2 Farmer PE, Robin S, Ramilus SL, Kim JY. Tuberculosis, poverty, and "compliance": Lessons from rural Haiti. Seminars in Respiratory Infections 1991;6(4):254-260.
3 Behforouz HL, Farmer PE, Mukherjee JS. From directly observed therapy to accompagnateurs: enhancing AIDS treatment outcomes in Haiti and in Boston. Clinical Infectious Diseases 2004;38(Suppl 5):S429-436.
4 Farmer P, Léandre F, Mukherjee JS, Claude MS, Nevil P, Smith-Fawzi MC, Koenig SP, Castro A, Becerra MC, Sachs J, Attaran A, Kim JY. Community-based approaches to HIV treatment in resource-poor settings. Lancet 2001;358(9279):404-409.
5 These efforts have also shaped the consciousness of young people, at least those on university campuses. For example, Face AIDS, a student advocacy group linked to Facebook, allowed undergraduates—from 18-22—to raise $2 million for programs to treat some of the poorest people in the world with the highest quality care available.
6 See, e.g. Gustavo Guitiérrez. The Power of the Poor in History: Selected Writings. Maryknoll, NY: Orbis Books, 1973.
7 Roberto Goizueta. Christ our Companion: Toward a Theological Aesthetics of Liberation. Maryknoll, NY: Orbis Books, 2009, p. 192
8 Ibid, p. 199.
9 Michael Roth. "Shoah as Shivah" in The Ironist's Cage: Memory, Trauma and the Construction of History, New York: Columbia University Press, 1995, pp. 225-6.
10 For more data on relief and recovery efforts after the January 12, 2010 earthquake in Haiti see http://www.haitispecialenvoy.org/relief-and-recovery/.
11 Martha Mendoza. "Would-Be Haitian Contractors Miss Out on Aid." Associated Press (December 12, 2010). Available: http://news.yahoo.com/s/ap/20101212/ap_on_re_us/cb_haiti_outsourcing_aid_1.
12 Farmer PE. The Uses of Haiti. Monroe (ME): Common Courage Press, 1994, 2003, 2006.
13 Malcom Gladwell. "Creation Myth." The New Yorker: May 16, 2011. p. 50.
14 This topic, the role of institutions in economic growth and social development, remains important today, as the work of James Robinson (see, e.g. Acemoglu D, Johnson S, Robinson J. Reversal of Fortune: Geography and Institutions in the Making of the Modern World Income Distribution. Quarterly Journal of Economics 118 (2002): 1231-94.) and Dani Rodrik (see, for example, One Economics, Many Recipes: Globalization, Institutions, and Economic Growth. Princeton, NJ: Princeton University Press, 2008) reminds us.
15 The historian Michael Roth has observed that "The privileging of irony is often the result of the inability to sustain belief in the possibilities of significant political change" (p. 148). His book about "memory, trauma, and the construction of history" is titled, with a nod to Weber, The Ironist's Cage.
16 Bill Clinton. Giving: How Each Of Us Can Change the World. New York: Random House, 2007, p. 4.