PHILANTHROPIC LEADERSHIP FOR SYSTEMIC CHANGE
|Main Speaker:||Paul Farmer, Founder, Partners in Health (View Dr. Farmer's PowerPoint presentation)|
Introduction by GPC Member Al Kaneb
Before introducing Paul Farmer, I'd like to briefly relate how my wife, Diane, and I came to be both Board members and supporters of Partners in Health, which I expect will be of interest to other Global Philanthropists Circle members who may be dealing with how and whom to fund, or to partner with, as we've been using more in the last few days, to achieve their desire to effectively invest in global philanthropy.
Our charitable activities, for twenty years prior to the year 2007, were primarily in more traditional modes of supporting universities, hospitals, medical research, homeless shelters, and the like, and there's certainly nothing wrong with that. And we got a lot out of it. In 2000, our focus turned to the AIDS pandemic, and our goal, however vague at that time, was to try to have a positive impact on those affected, try to help in some way to save a generation.
So we started out by going to some known names, and we first, with the help of UNICEF, set up a project in South Africa for orphans and vulnerable children, and one with Catholic Relief in Kenya. And then, in July of 2000, we read The New Yorker, Tracy Kidder's article, "The Good Doctor," which, if you haven't read it, was a 17-page piece, which ultimately led to the book Mountains Beyond Mountains in 2004, which was a New York Times bestseller.
And we decided we really needed to get to know Paul Farmer and Partners in Health. What we found, in Partners in Health, was a number of things that really attracted us to them. First of all, and most important, great leadership. You have Paul Farmer. You have Dr. Jim Kim, who's probably most famous for the "3 by 5" initiative of WHO when he was there; he's back. You have Ophelia Dahl, one of the founders, who was the Executive Director.
We found excellence in medical care, a preferential option for the poor, a totally patient-focused organization -- it's not an organization-focused organization, it's a patient-focused organization. They have creative efficiency throughout their entire years of operation. One of our potential supporters told me that's because they never had enough money. They are one of Navigator's top 10 slam-dunk picks to contribute to.
And they had a special vision, which really attracted us: namely, that it is wrong that millions of people die every year from curable diseases just because they're poor. PIH also has great partners: Harvard Medical School Department of Social Medicine, the Harvard School of Public Health, and Brigham and Women's Hospital in Boston, Division of Social Medicine.
We found particularly effective the PIH community health worker-based model. They actually pay their community health workers. In that structure, the community health workers monitor and support the patients in their homes, freeing the doctors to deal with critical cases. PIH's support is private, with thousands of individual donors, foundation support from Gates and Clinton and others, and multilateral support from PEPFAR Global Fund and others.
In our experience with PIH since 2001, the Haiti projects, which saw 100,000 patient visits in that year, in 2007 is up to 1.8 million. During that period, they were invited to enter into Rwanda, Lesotho, and Malawi, which they've done. In addition, PIH created new treatment protocols for multi-drug-resistant TB in their projects in Lima, Peru, and in the Russian prison system. These PIH programs have become world-recognized models for treating AIDS and MDRTB in the Third World.
I hope this has been informative for those who search, like we did, to find the right partner. May you find somebody like Paul Farmer, or better still, why not Paul Farmer? Among Paul Farmer's numerous awards are the MacArthur Genius Award and the Hilton Humanitarian Award. In addition to all else he does, he speaks at numerous universities and schools' international health meetings, as part of the PIH movement, which is to convince the world that health care is a human right. Dr. Paul Farmer.
Presentation by Paul Farmer
I wanted to start with something that's really quite specific, an example. In fact, I'm going to pick up where Al left off. This is my recollection of meeting Al and Diane. And since I have the microphone now, there's nothing they can do about it.
First of all, note that he said "in the year 2000," which was, alas, pretty early. Not early in the AIDS pandemic -- and, again, I'm just using AIDS as an example, because it's not the primary concern of 90-something percent of our patients in Haiti, and in Rwanda, for that matter. But it is the highest ranking infectious killer of young adults in the world, and certainly the leading killer of young people in many of the places we work.
I'm using AIDS, though, as an example, and it's a very important one for philanthropists to look back at critically, because the epidemic was already 20 years old by 2000. It had already long surpassed other illnesses as the leading infectious killer of young adults and children in Africa, with tuberculosis and malaria right behind. And when Al and Diane decided that this was of interest to them, it's not because they sensed some impending doom in their neighborhood of Western Massachusetts. This was purely out of solidarity.
And they came to Haiti shortly thereafter, and I didn't know that Al and Diane were large donors to other charitable organizations. Now I've worked with them for many years, but I didn't know that then, and we went to the clinic and hospital. And even though I'll be focusing on medical issues today, until the discussion, a lot of our work is invisible to a visitor, because it's not in the hospital, it's not in the clinic. It's in the communities and towns and villages that surround the places in which we work.
But we did spend time in the hospital that day, and then we went -- I live in the village, not inside where the medical center is, and this is in a squatter set-up in Central Haiti, very difficult to get to, not because of distance, either. And we had dinner at my house, which is small enough so that means you have to eat outside, and they asked me a question: "Why is it that there are so few AIDS orphans here?" This is my recollection. You can tell me if I'm distorting it.
And I said, "That's because we take care of their mothers, so they never become orphans." And they looked at each other in that annoying way that couples do, you know, so you had to wait and say, "Are they going to let me in on this story?" And they eventually did, not at that point, but later on, I found out that Al and Diane were major donors to a number of endeavors to help orphans.
The problem, at that time, and until very recently, is that without an effort to take care of the mothers and prevent orphaning, we can't keep up with the creation. We can't keep up with the rate of orphaning, especially in taking on an illness like HIV. So linking, at that point -- and some people in this room -- Mr. Gates will remember this, too -- there was a huge debate about, "Should we focus on prevention or care of this particular disease?"
Now, with tuberculosis, as an aside, you really can't have that discussion, because treatment is care. It's an airborne disease: you start someone on therapy, they become un-infectious. That's how you interrupt the cycle. But this was a very primitive discussion, and I'm going to show you an example of just how primitive it was among the experts.
So it's much better to have people who didn't define themselves as experts coming and ask this basic question, "Why are there so few AIDS orphans here?" when Haiti was the epicenter of the American -- in the sense of Latin America -- of the American pandemic. And the answer was, well, we started taking care of their mothers and preventing the orphanings.
So we later went to Africa a number of times together, and met with people who were just convinced that there was no way to integrate HIV prevention and care. Now, let me just show you where the expert opinions came from. And some of you have seen this.
But I know that you all read the Lancet every week. I have noted before that that's one of the great things about medical journals, is they have downwardly-mobile names. This is a very distinguished, one of the most distinguished, medical journals. But then again, the main journal for gastroenterologists in North America is called Gut, so. [LAUGHTER]
Anyway, so Lancet is a big deal in my circles, and these had been designed -- and I say this to my students at Harvard: sometimes when you see these things, you get asked, "Is this meant to start the conversation or to end it?" And I find it very useful. When I was young, I used to spend a lot of my time arguing, and I say to my students, "Don't waste your time. If someone is asking a question with an animus, don't spend more than 12.4 percent of your time arguing, because then, if you argue all the time, you'll have no time for actually doing anything."
But these were -- I took the authors off the abstracts, because I'm not trying to have an academic debate, but just to look at the confidence with which pronouncements like this were made. There's a curious specificity, I think, to the first one. You know, "Intervention A is 28 times more cost-effective than Intervention B" suggests to me -- I mean, I'm not an economist, of course. I couldn't possibly manage such sophisticated an arena -- you notice how economists change their mind every, like, 6 -- there's got to be a cycle. I think it's 6 or 7 years. I haven't quite nailed it down yet.
But it suggests that some things are fixed: cost and effectiveness, right? But let me just show you real-life data about cost. By the way, this doesn't matter -- it's an example, so don't worry that -- you won't be tested afterwards on, "What is HAART?" It's the treatment for AIDS, Highly Active Anti-Retroviral Therapy. But it's just the example I'm giving you.
So if something is declared to be 28 times more cost-effective than something else, you'd assume that cost and effectiveness are fixed parts of the equation. Well, here's what happened that same year, 2002: these were published in the run-up to a major meeting on AIDS, the major meeting, that happens only every 2 years, and I don't feel like they were meant to encourage those of us who are pushing equity and access to care.
Now, here's the numbers from that year. These are not from mathematical models; these are real-life numbers. So the average wholesale price of a 3-drug regimen -- to treat AIDS you need 3 drugs -- was $10,000 per patient per year. Obviously, well beyond the reach of even poor Americans, much less poor people globally. And I will be using this to return to the notion of systemic change.
Partners in Health, at that time, as Al says, a very small organization, was still able to find, with a mix of generic and prices fixed for us by the drug companies -- from the big pharmaceutical companies, but lowered for work like ours -- was paying between $600 and $700 per patient per year. And a group called the International Dispensary Association in the Netherlands, which is the world's largest non-profit distributor of drugs, had already renegotiated the prices to $300 to $412. And this is before President Clinton and Ira Magaziner and others got involved in renegotiating the prices again and again.
So in the very year that confident claims about prevention versus care were being made, at least in terms of cost, there was not a fixed number. And, you know, obviously, I put these numbers together to go and engage in battle at this AIDS meeting, but I had my own reasons for engaging in battle: I'm a doctor. And of course I can't afford to use economic rationalizations for people coming into our clinics and hospitals, and if you're working in an area like central Haiti or rural Rwanda, you don't want to find yourself having to justify to a patient or their family member, "Gee, I'm sorry, we can't use this therapy because you are" -- and then fill in the blank: Haitian, poor American, whatever it may be.
And I have to say, in my 25 years of working in Haiti, I've never had someone come up to me and say, you know, "I'm sorry to learn that I have AIDS, but since I'm a Haitian woman, it's not going to be cost-effective to treat me. Forget it." That has never happened.
Anyway, back to scale. This has been the big tension of our lives, and the original founders of Partners in Health, we all still work together, including Tom White, who's 87, and the people that Al mentioned. So it's a group that's grown very dramatically, but we haven't lost people. That's why we call it Partners in Health; the idea was that more people would join us, and we wouldn't have people come and then go.
That's a bit of a warning to all of you, by the way. It's like, there was something in America called the "roach motel," and it was a way to kill roaches. And the advertising was, "Roaches check in, but they don't check out." Anyway, so Partners in Health is like that. [LAUGHTER]
So the scale-up: we have been living with this tension all of our lives, and because we wanted to have excellence and community-based programs that would lead to systemic change -- and just to go back to the systemic change issue, the way that we saw it is that there is a -- you know, everybody sees this -- there's a vicious cycle between poverty and disease. And the question that we were asking ourselves when we were a little bit more experienced was: is it possible to break that cycle? And the answer is yes, and people all over the world have broken that cycle.
And there are places in which that cycle has not been broken, and we said, "We want to be part of that effort to break the cycle of disease and poverty." And we believe very strongly that it could not be done by ignoring the root causes of poverty or the root causes of disease, which are very similar. Nor could it be done by ignoring, for example, the destitute sick: people who already do have malaria, or people who break their arms, or women who have obstructed labor. Ignoring those problems is not the way to break the cycle of disease and poverty.
So it's been very difficult to be rooted in a community, to have a great deal of attention to detail and, we hope, excellence, and to try and bring this to scale. And I have some friends who are gurus in health policy who have assured me it is not possible to bring this to scale. They're just convinced it's not possible. And they may be right, but I can tell you that we've also heard people say, "You can't do this across central Haiti in the public sector."
And our answer was, "Well, we can't know that we can't do it until we try and fail, so let's at least try." And every place there's a red dot, we have gone into the public sector facility -- not like the one we built ourselves -- and rebuilt it at the same time we were doing two other things: taking care of the sick and training people, locally, to do this work. So those three things we did in each of these places: rebuilt public health infrastructure -- and often from scratch, and sometimes not; sometimes it was rehabbing, as I'll show you from Rwanda in a second.
And then I thought, "Well, this is pretty good." You know, this is what we promised to do with this funding, was to bring it to scale across central Haiti. This is about a quarter of Haiti's surface area, by the way. And, as Al said, last year, we had 1.8 million patient exchanges. And I'll be switching very shortly into this broader question of systemic, but we thought, "That's pretty good. That's scale." And they said, "No, that's not scale. That's contiguous spread." And they were dead serious; these are my friends and peers. They said, "That's not bringing it to scale. Scale is only national."
Now, I didn't ask them what I later thought, after I heard this, is, "How do you know what scale is?" But I didn't. I said, "Okay, well, we'll try harder. And we'll go to Africa." You know, people said, "Well, you can do this in Haiti, but you can't do it in Africa," but we did; we went to Rwanda, and they said, "Well, you can do it in Rwanda, but you can't do it in Lesotho." And so we've been, all our lives, chasing these challenges, which are, again, meant sometimes specifically.
Anyway, we had a visit from a noted philanthropist. I won't mention her by name, but her father-in-law is here today. And she came to rural Rwanda with Patti Stonesifer, who many of you will know. And they came to do a visit. And they were listening a lot. They didn't really talk very much, and they were listening to the health workers, the doctors, and the patient groups and the women's organizations. And at the end of this visit, this day, we were, again, sitting at my house, and they said, "Well, what you're trying to do is start virtuous social cycles."
So, being an academic -- part-time academic, anyway -- I said, "Did you guys make that up, 'virtuous social cycles'? Because I think that's just what we're doing. Can I use that in my writing?" They said, "Knock yourself out." So since then, we've been -- you know, we've tried all these different ways of describing what we're doing -- breaking the cycle of disease and poverty, etc. -- but this is just as good as any, because we use AIDS and even AIDS funding to address much broader and systemic problems. That's what we did with our Global Fund grant, and it was not easy to do, and some of you will have questions about how we managed it, to take what's called a vertical program and integrate it, but we did.
Not only that, it allowed us to meet children who weren't in school, to meet people that didn't have water, and to work with local communities to think about housing, and all these other, broader issues that concern -- when you take a slide like this to remind one to talk about these basic necessities, this pretty much covers a lot of people in this room. Those who want to fight poverty and deal with the problems of people living in poverty know that these are invariably the ones that they talk about.
When someone is dying of a disease like that or any other disease, they'll talk to you about their own ailments. But as soon as they get better, they start talking about their children not being in school, not having enough to eat, not having a job. So we have tried to listen. In order to address systemic change -- and it was the message of my colleague from Mozambique, you really need to listen to people. And I believe you said, "Listen, listen, listen."
And when one does, of course, you not only get to hear about all of these -- I'm not going to call them problems, but these challenges, and you get to hear about many others. And we've had to focus a lot on food security in rural Haiti and in rural Africa, in the 3 countries where we're working, because these are the kind of problems people are having. But we have tried to regard them not as a burden, but as a great privilege and an opportunity. You know, we're able to enter the life worlds of people living in poverty and work with them on addressing poverty. I can think of nothing more gratifying than that -- at least, I've never been.
And that's what took us to Africa. I went with the Kanebs to Kenya, and then -- well, before that, I'd gone to Rwanda on a preliminary visit, with people from the Ministry of Health, to look at a hospital in northern Rwanda. Some of you will know the town of Ruhengeri. And it's where people go to see the gorillas, which I also did that day, in pretty much the same outfit I have on now, so you can imagine how the gorillas and the Europeans looked at me.
But I left the gorillas and went to the district hospital, and there was electricity, an X-ray machine, 3 physicians, a very under-stocked but functioning laboratory, and it was clean. This is a public sector facility. And so I went back to the capital, Kigali, and I said to the Minister of Health and the Director of the National AIDS Program -- we were doing this work with the Clinton Foundation, and we are doing this work with the Clinton Foundation -- but I said to the Minister, "You know, you can send us someplace more difficult, because we're from Partners in Health." Again, it's called public health machismo. [LAUGHTER]
And, you know, "we're used to tough conditions. We're used to much worse than this." So he and the Director of the National AIDS Program looked at each other, and they said, "Okay, fine." [LAUGHTER] So that's how we ended in up in Rwinkwavu. Linda, you were asking me the name of the town. We found it on a side. So this place had been abandoned since the war and genocide in 1994.
And it's not what people here are thinking about when they talk about systemic change, but I've already talked about some radical transformations in the lives of individuals like Joseph, in the lives of communities, like the public health sector services we've rebuilt, and our own transformations, you know, as people who, maybe 15 years ago, would have said, "I went to medical school not because I was interested in food security or clean water; I wanted to take care of the sick." We don't do that. We say, "Well, it's our privilege to take on these problems much more broadly."
So to go here, I have to say, even though I told it as a joke, we did feel confident that we knew how to rebuild an abandoned hospital at the same time we were taking care of the sick and training people. We felt confident because we'd done it in Haiti, and we brought the Haitians with us to Rwanda. Now, people talk about South-South solidarity, or kind of other romantic things. People like Dr. Daisy Grey, who is Joseph's doctor, went to Haiti with us to help us, especially to help us recruit and train people.
And they did something else, which I only dimly recognized at first; now I think I'm getting it: they inspired a great deal of hope in the Rwandans, and later in Lesotho and Malawi, because the people living there had very little reason to trust NGOs or development people or even philanthropists. Why would Rwandans have faith in us? What have we done there that would be compelling to them? The answer is nothing.
So the Haitians, having them there to speak in a somewhat different way than I could, to say, "This will work here, just as it did in Haiti," with great conviction, was very helpful. And, of course, it did work. You know, the pediatrics before and after, this is only a few months apart. And this is, again a public hospital. You know, the people of Rwanda own it.
And then we also said, "Well, we're going to pay attention to the way these places look." Because if they're filthy or ugly, what does that say about the people who you're asking to attend them? What does it mean when you have a public facility that's not well-kept? And, so, some people looked askance when we said, "Well, we're going to make it beautiful." And this is the public hospital before, and the public hospital a year later, and it's not magic, any of this.
And it's not even expensive. I'll show you the costing exercise: the amount of money that we put into the entire project the first year, in an entire district, was less than $2 million. And the infrastructure rebuilding was less than 5 percent of the overall expenditure. So these transformations are not expensive.
And let me just now go to this systemic question. So how do these vertical health projects have any impact on systemic change? These are modest endeavors, by the standards of many. And, you know, I've spent too many years of my life apologizing for how small, or our failure to scale. And I don't do that anymore, because I think if we can build very good projects in certain districts in the public sector, we introduce the possibility of bringing things to scale, which is what we're trying to do in Rwanda.
And President Clinton and Ira Magaziner, I have to say, are people who pushed us to do a costing exercise in Rwanda. And one of my responses was, "Wait, we have to work all day and all night seeing sick people and training, and we also have to do a costing exercise?" And he said, "No, no, no. I'll send some finance guru." And he did. He sent a team of people, headed by a woman named Diana Noble, and they just went through all of the expenditures of the first year, all the receipts, all the books, and everything. And this is what they came up with, some of which surprised me and may surprise you.
So, first of all, I don't think it's embarrassing -- this is already 1,500 people working on this project, all Rwandans. And 1 or 2 Americans, 1 or 2 Haitians, 1 guy from Cameroon. But 99 percent Rwandan. So in the middle of 60 percent unemployment, is it embarrassing to spend 45 percent of your budget on labor? I don't think it is.
And in the middle of food insecurity, it may be surprising -- it surprised us -- that we spent 20 percent of the budget on food, more than on medicines. But it's not embarrassing. That's why we were getting ready to link our efforts with agricultural and development efforts. But in the first year, you can't say, "Gee, wait, stop starving until we get the agricultural component in." There's only one treatment for malnutrition, and that's called food. And I went to Harvard Medical School; I should know. [LAUGHTER]
You'd swear, by the way, it takes, like, 15 NIH grants to decide that the treatment for hunger is food. And they will do that. Trust me. But you can see that a lot of what we spent our money on is not what was expected. And, you know, infrastructure, by the way, was 4.5 percent. So rebuilding these facilities, or building them, was a very small part of our overall cost.
And then also, as Al noted that we stipend our community health workers, they get a stipend. And the reason he brought that up -- and some of you will be familiar with this debate; for others, it will seem arcane -- the reason is because a lot of people in the development world, and in international philanthropy, say, "We'll have community health volunteers. We can't pay them; it's not sustainable." And what we've tried to say is: it's not sustainable not to pay poor people for their labor, which, again, is a radical notion to some.
By the way, people like me, if we're consultants, we get paid through the nose. My peers are well-paid. And that's one reason I have a faculty appointment at Harvard, so that I can say, "I don't want to be a consultant. I want to do this as a volunteer." But it's just crazy.. And I'm sorry that Mr. Gates is here, because it makes me more reluctant to be praiseful, but I have to say the Gates Foundation did CPR on international health. It was a very moribund field in the late '90s.
It was full of hangdog pessimists. You know, my peers and my age-mates even. It was not a daring, entrepreneurial arena at all -- very hide-bound and conservative in the late '90s. People had given up on a lot of what they thought we could do back in the '70s. I was a child in the '70s, but you read about the primary healthcare movement -- people had all but given up on that. So it was a very good thing when these new resources came into play. And it's radically changed the arguments, like the one that started in 2002 is really gone now.
So the question that I would have -- and this is a question I'm opening -- is if we think about breaking the cycle of disease and poverty, and we know there are new resources, how can we broaden those resources? How can we make them serve less vertical or focused programs, and focus more on this broader effort to rupture this cycle? Because if we don't, all the new developments in global health, whether they be for new vaccines or diagnostics, they're not going to reach the poorest. They're going to be stuck in this bottleneck, where they are stuck right now.
You can't get these new technologies out to the very poor, because there are no community health workers, there are no public infrastructures through which we could scale up these endeavors, and that's what Partners in Health does, is try to rebuild these infrastructures and recruit a new army, really, of community health workers to do this work. So thank you, and I'd like to open it up for discussion.
Questions & Answers Session
QUESTION: This question comes a little bit informed by the last conversation that we had before lunch. And somebody -- just to fill other people in, someone in our group had said that they had worked for an organization where they had decided that Haiti was too difficult to fund; there wasn't enough infrastructure. You translated that to say, "Too poor." But the need is so great. How do you decide where to put your effort and energy? I mean, you had to choose Haiti; you chose Rwanda. How do you, and how would you recommend people in philanthropy, make those decisions?
PAUL FARMER: Thank you very much. You know, in speaking to philanthropists and global leadership, I would say that going for the gold means taking on the worst poverty, and going to the most difficult places. So the exact opposite logic that was used by the person saying, "We can't work in Haiti because it's too unstable; there's no infrastructure," which is really tantamount to saying it's too poor to help.
But real daring philanthropy is going to have to go for the gold, and going to have to be willing to -- you know, someone recently mentioned to me -- all those of you who are venture capitalists, forgive me, but I've noticed that venture capitalists always think they have the answer to every question. And they may; I don't know. But one of them said, "Well, what you're arguing is a lot like what we do. You have to be willing to take enormous risks."
And, you know, I feel that it's exaggerated from both venture capitalists and philanthropists to say they're taking risks, because it's people living in Haiti or Rwanda who are facing real risk, not us. But I think that's true. The analogy holds firm that to be risk-averse in philanthropy is not good for the cause that you're addressing through Synergos. And it's the opposite of what we need.
So I would say choose based on need. You know, we work in this country as well, in the United States, which, you know, has no national health insurance program, etc. It's not that it drives us away from working in a place like Russia, which is not a poor country, or the United States. It's that we also spend a lot of our time focusing on the really most difficult places and difficult cases. And that's what I would recommend to philanthropists, as well.
You know, betting on something that's sure sometimes leads people away from the hard tasks of social justice, for example, as was brought out by Daniel earlier, and towards something that feels more comfortable, but, in the end, will not break this cycle. And I think this cycle of disease and poverty is related to violence and all sorts of bad things that happen in the world today. I may be wrong, but that's my hypothesis, so I'm hoping that people here will be drawn into this.
I mean, I'm thinking of Mozambique right now, because we have someone distinguished from Mozambique, but I'll bet you that what I'm saying is not -- you're not going to disagree with it either, that, you know, this cycle has to be broken, and it's related to -- you know, poverty and inequality are related to violence, I'm quite sure. Thank you.
QUESTION: There's an initiative that is called the Young Global Leaders, from the World Economic Forum, and they are working on a project that is called -- well, a program that is called de-worming. I don't know if -- well, 2 billion people from all over the world have worms in their stomachs, and the treatment is very cheap. It's like 50 cents per child per year. So I know the Gates Foundation is working with this cause. Have you thought about investing in this project? And the reason why I am telling you this is we are starting working on a documentary, to promote this, to generate awareness on this cause, and to raise funds all over the world, so I just wanted to know if, later on, next year, when we have it, what can we do, in order for you, with your team, work together for this initiative?
FARMER: Well, first of all, thank you. We are part of that effort. And I've focused on one disease today just to make a point, but we don't focus on one disease. So we've been part of this global anti-worming crusade for many years. Again, here we are in the middle of Manhattan at this really fancy place; I'm trying to think, "Has anyone ever said 'global anti-worming crusade' in this room before?" [LAUGHTER]
So, A) we are working on it. We'd be glad to work with you. B) I would say -- and back to the previous question -- to me, that's also going for the gold, not because it's an ambitious, integrated effort, but because it's slated for the most vulnerable children. So there are different ways to go for the gold. I advocate integrated primary healthcare, as do many in my field, but when you focus on the diseases of poor people, you're still addressing something very, very different from what, you know, many other philanthropists in the world. They don't focus on poor people's problems at all.
And this is a critical forum, so it's fine for me to say look at the difference between, you know, worthy causes to support the arts in a city like this and de-worming children in rural Africa. This is not the same thing. So that's what I also mean by going for the gold, is going for the persistent problems of people living in poverty.
QUESTION: Dr. Farmer, first of all, thank you very much for sharing your extraordinary experience. I have -- I don't know if it's a question or a comment. The first one is about your examples of an integrated approach to, for example, defeating AIDS, which is not common. In fact, during this conversation, some colleagues were arguing that you have to focus, you have to choose, specifically, what you want to do. And you're arguing that you cannot do that unless you deal with water and infrastructure and so on. I wanted you to elaborate on that.
The second thing, again, which is not common, is you're working through the public system. So, more often than not, people will say, "Give up. The public system will never deliver, so you have to have your own project, aside from it." And here you are, arguing that you are strengthening the public system.
And my third comment, or question, I don't know what it is, is I would like to know how many of your team in Rwanda are medical doctors, of the 1,500, because, in Mozambique -- and I'll stop here -- we are 20 million, and we have 900 doctors.
FARMER: Thank you. Well, let me start with the last point, because it'll reassure you. And I should have said it already. Only a handful of the 1,500 are doctors. The vast majority are community health workers. Just as Rwanda -- you know, it's estimated -- and this is not as bad as Mozambique, but after the genocide, this country of 8 to 9 million people had only 500 surviving doctors. And they were almost all in the city.
When we went to this place with a half a million people, there were no doctors at all. Zero. So having a dozen doctors there now, of whom 2 are American, 1 is Cameroonian, and 9 are Rwandan -- this is just to give you an idea -- so there are 9 doctors out of 1,500 employees.
Back to the first and second points: you're right, and I appreciate you underlying this, these are not common. You know, people say, "It's just common sense." Well, it's not. It's not common sense to say -- you know, in a rural area, if you have only a vertical program, focus -- because I understand the desire to focus; who wouldn't like to focus? I mentioned, obliquely, you know, being a sub-specialist physician, and an infectious disease physician, the whole point of a training like that is to focus your attention on very limited problems.
But unfortunately, poverty and inequality mean that the problems are not focused. They're diffuse. And to put this in starker terms, what am I going to do in rural Haiti? And I know you're saying this so I can -- you're allowing me to say this. If I'm sitting in rural Haiti or rural Rwanda or rural Mozambique, and a woman comes in in labor, obstructed labor, what am I going to say, "No, we're the AIDS program, go to the obstructed labor program next door?" There is no obstructed labor program.
The possibility for focusing one's philanthropic interests are greater than the possibility of focusing one's activities as a provider. So we don't have the luxury of focusing. You do. Of course, I'm also encouraging you not to focus overmuch.
So philanthropists can focus their attention; we do not have that luxury. And for the same reason you said Mozambique has so few -- 900 doctors for twenty million people -- that just is an example of why you can't focus, or why you can't count on positions.
And the second point you made, and allow me to underline: the idea of working in the public sector, which everyone else had given up on, was more a revelation than common sense. Because we said, "Well, what have we done wrong in our work in Haiti, after ten or fifteen years of working very hard?" And the answer was, "You've let the public sector collapse, with all these cheerleaders around saying, 'Public sector's hopeless. Privatize. NGOs. Anything but the public sector.'"
And then we stopped and said, "Well, why this cheerleading for privatization, and where does it come from, and what does it mean, and what does it mean, especially, for poor people? Not ideologically, because we're really not that interested in the ideological battles. We're saying, "What could we do to break the cycle of poverty and disease?" And one of the things we have to do is promote, as Al said, in introducing me, we have to promote basic rights: to healthcare, to clean water, to primary education, at the very least.
And if we do that, then we say, "Wait, can you people in this room, can Synergos, offer rights to the poor in Africa? No. Can Partners in Health offer rights, the right to healthcare, in Haiti, even with twenty-five hundred people working there? No." The only people who can offer the right to healthcare is the public sector to its own citizens. So we had to go through a massive and uncomfortable rethinking of our own strategy a good fifteen years into working very hard in Haiti, and say, "This is a mistake. For us to develop a parallel system and allow everything that's commonwealth to flounder, really, is the wrong approach."
So that's why we're expanding only in the public sector. And people talk about the brain drain internally, the NGOs sucking up all the best talent inside Mozambique or some other country in Africa. We're saying we're not going to be party to that. We're brain-draining people back into the public sector, in Lesotho, Malawi, Rwanda, Haiti, Peru. You know, and that's part of our job now. We just didn't understand it, because we were taking too commonsense an approach, a commonsensical approach, when we really needed to stop, step back, and say, "We will never address systemic problems if we can't rethink the way we're doing our work." And that is a very painful experience, because we had to redo a lot of our programming.
QUESTION: Hi. From the stories that you tell and the experience that you present, it is obvious that you work very closely with the communities you serve. That's a very important value for Synergos. I would like you to develop a little bit more on how do you approach community, what strategies that you use to relate to the community as a part.
FARMER: Well, in spite of my insisting on the importance of the public sector, our approach is still to go to community-based organizations. So an example, so that doesn't sound so vague: everywhere in the world that I've been, poor people have organized themselves in one way or the other. Women's groups -- in Rwanda, for example, I was very surprised to see that people living with AIDS had organized into groups even though they didn't have any therapy.
And yet, when we got there, they were already organized internally, and so a lot of our initial employees -- virtually everyone who started therapy for that particular disease in that year, 2005, almost all of them work for us now. Or we work together. So that way of approaching -- of course, you know, you learn lessons in Haiti that are going to be useful in Mozambique or Rwanda. There's cultural specificity, but there's also structural similarity. You know, poverty and inequality even in Brazil, you know, has similar lineaments in different places.
So we go in, I hope, with the experience of working among the very poor in Latin America, which teaches us, gets us ready, to work in Africa. I think that's why we could move very quickly in Rwanda, is because we had that experience. But then we look for people.
And then, back to the public sector, you know, you're lucky, sometimes. We were lucky in Rwanda, I'll admit it. We found great public servants, even at the highest level, who really cared about their population. But my experience across Africa is that there are great public servants in every country I've been to. You know, and I haven't been to that many of them, but I've been to a dozen countries in Africa, and there are really good public servants. So we found them, too.
Now, you can luck out and go to a place where there are not great public servants, but that's the minority of cases. And, you know, the places we work in Africa are different enough so that I'm confident that, there are always good people to work with in the public sector.
QUESTION: It's interesting to listen to you after having read Mountains Beyond Mountains, the dichotomy between you here in a suit and in this setting versus the book, your biography, talks about being there. So it's a personal honor to be here. I'm wondering if you can talk a little bit about the person struggles you have. In the setting this morning, we talked about -- one of the speakers, Ambassador Hunt, talked about her child wanting not to be overwhelmed by her lifework in some sense, and yours is even more out there.
You're living it, and while some might call it great personal sacrifice, I'm not sure how you think of it that way, because if you thought about it as purely sacrifice, you probably wouldn't be doing it. So I'm just curious if you could help those of us who, either for ourselves or thinking about our children, trying to think of role models, how does one think about making the kind of commitment and contribution that you've decided to do in your life?
FARMER: Well, you're absolutely right. I don't regard this as a sacrifice, or one would never be able to sustain decades of engagement, which is what this work needs, is people to be engaged, whether as practitioners, implementers, funders. But it really requires lots of patient engagement. And I don't feel that it's a sacrifice at all. I love this work, and I could imagine doing no other work.
And one of the things I try to do is share with younger people, especially, how exciting this work can be. And that's true, I suspect, for many of you, as philanthropists or people who are steering the movement or working on sort of this side of the great gap or divide between the very poor and the non-poor. So that's part of it, is it doesn't feel like a sacrifice at all. It's very invigorating, rewarding work.
I'm lucky enough that my family works -- we work together on this, because they also agree that it's exciting, rewarding work, and they wouldn't do any other. I think that it is not -- I don't go around suggesting, you know, "You should do what I do." I would never say that to anybody. I wouldn't say it to my closest student, you know, or protégé, or mentee. I wouldn't do it, because I think that's a mistake, for all of us to advise others to do something that we're doing. You know, I think the best we can do is say, "This is very engaging and exciting to me. I recommend it or some aspect of it to you." But how one gets involved in this work, I think, has to be very broad.
So anyway, the energy I get from, you know, being around people who are fighting back against poverty, and making headway, has been the main source of inspiration for me. But also, meeting people who have -- you know, again, I don't want to -- I mean, people like some people in this room really do not share the kind of burdens that are faced by almost all the people I serve directly, so their engagement is purely out of principle or solidarity or something else noble like that. That's inspiring to me, too.
Well, thank you all for having me. It's a pleasure.
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