Paul Farmer Speaks to the Next Generation: An Excerpt from His Book

Travel back with me to the early 1980s, when I first went to Haiti. A college class at Duke University got me interested in health disparities and also piqued my curiosity about Haiti, where I headed shortly after graduating. I ended up in a sleepy market town in central Haiti called Mirebalais, living in the rectory of an Episcopal church and working in a hot, overcrowded clinic.

My job was to take vital signs and to give moral support to the beleaguered young physician. We became good friends, and in time he confessed how tired he was of working in such a shabby facility. But he never did much to change it. The doctor, not yet thirty, had been schooled for scarcity and failure, even as I’d been schooled for plenty and success. Even though he himself was not poor, working in that clinic had lowered his expectations about what was possible when it came to providing health care to those living in poverty.

And who could blame him? The same verdict was being drawn by most “experts” in international health at that time. As today, Haiti was the poorest country in the hemisphere and thus had one of the greatest burdens of disease; the magnitude of its challenges was difficult for me to comprehend. But the assumption that the only health care possible in rural Haiti was poor-quality health care—that was a failure of imagination.

I’ve since learned that the great majority of global public health experts and others who seek to attack poverty are hostages to similar failures of imagination. I’m one of the bunch too, of course, and am telling you this because it’s taken me a long time to understand how costly such failures are. Every day in clinic offered vivid reminders of the toll exacted by a lack of imagination.

It wasn’t a failure to work long hours—we all did that—but rather a failure to imagine an alternative to the kinds of programs that the public health literature deemed “realistic,” “sustainable,” and “cost-effective”—three terms already in circulation by the late 1980s. Most of my Haitian colleagues were, like the doctor, unconvinced that excellence was possible. My experiences in Mirebalais that first brutal and instructive year inspired a lifelong desire to see, in Haiti, a hospital worthy of its people.

Mirebalais, in 1983, was also where I met Ophelia Dahl, and Father Fritz and Yolande Lafontant, who took me in as a volunteer. All of us had figured out, with hope and angst and revulsion, that rural Haitians deserved better medical care, and a couple years later, this group founded Partners In Health along with a few others picked up along the way.

None of us imagined that a greater affront to Haiti would occur on January 12, 2010, when a massive earthquake laid waste to Port-au-Prince. The quake forced us into the role of a disaster relief organization in addition to that of a health care provider. It also made us completely rethink our plans to build a hospital in Mirebalais. With Haiti’s national nursing school destroyed and its medical school damaged and closed, with most of Port-au-Prince’s hospitals down or in shambles, where would the next generation of Haitian health professionals train?

Partners In Health supporters had sent thousands of donations for rebuilding. But they wouldn’t be enough to rebuild something really bold and beautiful; we needed something bigger, many times bigger. Together, a crew revised plans more than a dozen times, enlarging their scope again and again, and making it, in the end, a 205,000-square-foot medical center. That was three times the size of anything we’d ever attempted to build before. Let’s say that these plans were our response to inveterate failures of imagination.

To some, the hospital is just a building in progress, one project among many. But for me, it’s emblematic of our respect for the Haitian people and of our aspiration to make the fruits of science and the art of healing more readily available to people in sore need of them.

How does this story relate to you? First, try to counter failures of imagination. A great many people, including public health experts and some of our own coworkers, shook their heads and advised against the more ambitious version of the Mirebalais hospital. I’m not saying they were wrong. It will be a long time before we can declare this effort a success. Hospitals are the bedrock of every health system, but they are large, expensive, complex institutions to run. The complexity of hospital-based care is one of the reasons public health starts with the low-hanging fruit: vaccines, family planning, prenatal care, bednets, hand washing, and latrines.

But the more difficult health and development problems—from drug-resistant tuberculosis, mental illness, and cancer to lack of education, clean water, roads, and food security—cannot simply be left for a better day. What about the higher-hanging fruit? Do the tools and strategies of global health permit us to care for people with more complex afflictions? Can we answer more of the need?

The short answer: of course we can, with innovation and resolve and a bolder vision than has been registered over the several decades.

Second point: as you seek to imagine or reimagine solutions to the greatest problems of our time, harness the power of partnership.

Partnership has been the font of our work since it began in Mirebalais three decades ago. It’s why we refer to our collective as Partners In Health in a dozen languages. Sometimes, these are partnerships among service providers, teachers, and researchers. Always they are partnerships among people from very different backgrounds (within one country or across many). Sometimes the partnerships link different sorts of medical expertise—surgical, medical, psychiatric, and so on. Sometimes they bring together people who design and build hospitals with those who know how to power them with renewable energy or link them to the information grid.

Above all, such partnerships link those who can serve with those who need services—and seek to bring the latter group into the former, by recruiting them to act as community health workers, for example. By moving people from “patient” to “provider” and from “needy” to “donor,” we can help break the cycle of poverty and disease. That’s our sustainability model.

Partnerships are not always easy to maintain. Often competition rules when collaboration should prevail. People working to fight poverty are, like my doctor-friend in Mirebalais decades ago, too often schooled for scarcity. Where joblessness is the status quo, building new hospitals and schools can bring disappointment to some: everyone wants to work there—and usually not because they want a better job, but because they want a job, period. If someone else gets a job, our colleagues assume that they will not.

This sort of limited-good, zero-sum thinking is to be expected among those living in poverty, who know from firsthand experience that good things usually are in short supply. But such thinking is less acceptable among goodwill groups (foreign or homegrown) and among development experts seeking to attack poverty. Poverty will not surrender to a zero-sum strategy. And neither will the other great challenges before us, from global warming to prolonged and equitable growth of the world’s economy.

Remember that your own success will not come without real partnership. Do not think of it as coming at the cost of someone else’s success. As new challenges arise to the survival of all dwellers on this planet, your generation, more than any other, will need to embrace partnership.

Adapted from To Repair the World: Paul Farmer Speaks to the Next Generation (University of California Press, 2013).

Dr. Paul Farmer is chief strategist and co-founder of Partners In Health, Kolokotrones University Professor and chair of the Department of Global Health and Social Medicine at Harvard Medical School, and chief of the Division of Global Health Equity at Brigham and Women’s Hospital in Boston. Check for his speaking events in your area.