Nuggets From Paul Farmer's Call
Posted by Pavi Mehta on Dec 24, 2020
There’s a thread you follow. It goes among
things that change. But it doesn’t change.
People wonder about what you are pursuing.
You have to explain about the thread.
But it is hard for others to see.
While you hold it you can’t get lost.
Tragedies happen; people get hurt
or die; and you suffer and get old.
Nothing you do can stop time’s unfolding.
You don’t ever let go of the thread.
Moderator Cynthia Li opened last Saturday's Awakin Call with this poem from Paul Farmer's new book, "Fevers, Feuds and Diamonds: Ebola and The Ravages of History." It rang through the space like an invocation, and set the tone for a conversation that took many of us by surprise--Paul included."Coming into this interview I thought --they are going to drop my blood pressure down to 80 over palp-. They are so mellow -- but no! You've gotten me worked up with these questions. They are really the questions I struggle with the most -- and that I want to struggle with. So thank you."
Paul Farmer is a doctor, anthropologist, Harvard professor, and “world-class Robin Hood” who has dedicated his life to improving health care for the world’s poorest people. Since 1987, he and Partners in Health, the nonprofit he co-founded, have revolutionized international health care, pioneering strategies for delivering novel, high-quality and community-based treatment in resource-poor settings. In 2010, when an earthquake demolished Haiti, Farmer was there. In 2014, when the Ebola virus erupted in Sierra Leone, Farmer was there, too. Whereas others might understandably flee such crises, Farmer runs toward them. Farmer once confessed, “I can’t sleep. There’s always somebody not getting treatment. I can’t stand that.” Known as “the man who would cure the world, his life story was captured by Tracy Kidder in the New York Times bestselling book, Mountains Beyond Mountains.
Paul's presence vibrates- something issues forth from him that's akin to the sound from those old church or temple bells. Days later you still feel the reverberations.
"Going back to Haiti after being away because of COVID-19 will be another chance to renew my- well-- vows-- I might as well say that." Vows. He used the word only once. It conveyed a world of meaning.
Listening to Paul one hears the voice of genuine humility, and the voice of restless compassion. You cannot miss his profound work ethic or that potent combination of anger and love that has magnetized thousands around the world. His is the voice of someone who for decades has been reminding humanity, in word and deed, of its deepest vows to one another. Last Saturday's Awakin Call had the same effect...
A handful of bracing quotes from the interview--
- I was fighting against the notion that we would not deploy the basics of critical and supportive care to save lives in W Africa-- and that includes simple things like IV fluids. And if you've been paying close attention to other epidemics - Ebola, cholera etc you would have seen this played out in Yemen, Haiti-you can go through the list. "Sorry all you need is oral rehydration salts, even though you're vomiting." You see that once and you don't forget it. You see it several times and you develop a real animus. And I have that animus. I am upset by that logic.
- Of course we'd love to be paragons of virtue but no one can sustain that kind of exposure to suffering, and happily it doesn't have to be prolonged so much as it has to be sincere. And that's the real beauty of this work-- it never fails no matter where you are. Every single time it is possible to make human connections. They may be glancing and brief, and they may not be accompanied by deep cultural insight, but they are there, and you can see them. Being present to people is the key in my view -- it is the key.
- Getting to know people in their hour of need is a deeply rewarding gift, What is the price of admission for that gift? What's the price of admission when you are carrying people in their darkest moments? My price in any case was learning about those ravages and laying them out on paper.
- It was very difficult to write about Ibrahim and Yabom. Ibrahim was 26 when he fell ill with Ebola and lost over 20 members of his family. That was a new experience for me. I didn't know other patients who had lost so many family members to one pathogen. Yabom was 38, she was a young mother and spouse when she fell ill, and she lost children, her husband, her mother. I met these people at their lowest point. A real friendship came later as the real Ibrahim and Yabom came out of their grief. But their stories were so overwhelming.
- I think a lot of us in public health and global health equity are very much intimidated by the voices of development economists who will say, "That is not cost-effective, feasible, sustainable." A bunch of jargon and buzzwords that are not always backed up with data-- so why would be back them up with conviction?
- You know how people will tell you you need cultural competence? That's an absurd idea. I know anthropologists who have worked for 40 years in one place and who are not culturally competent in discussing the language and culture of the place. Why would we think we could become culturally competent in the course of medical school or nursing school? So I push instead for cultural humility. When you have that going in you're going to learn all kinds of things.
- The primary unit of caregiving is the family. And in a lot of places I've worked, the secondary unit of caregiving is traditional healers. I regard them, not as the competition, but as our coworkers. Finding ways to work together has been a universal constant as well -- even in the clinical desert where you are trying to put in place a safety net. The need for safety nets is another constant. Even affluent countries that don't have them are going to suffer-- as we are now in the midst of the COVID 19 pandemic here in the United States.
- Here's another universal principle: Anywhere you go, if you go as a caregiver, you will be recognized as a caregiver and welcomed. In a prison in Siberia, in a Navajo town, in a squatter settlement in Lima or rural Haiti --it's the same thing. Of course there are exceptions, but they are rare. Another universal principle: When people are ill or injured what they are looking for is care. The kind touch, love, support--they are looking for care.
- The place I'm most at home? My garden in Miami or Haiti. They both have koi. In the hospitals too. You have to have koi for a garden, and you have to have a garden for a hospital.
- Health security is not going to come out of the kind of security you get with armed peacekeepers after a conflict has ended. It's going to come with a safety net, and particularly with insurance, education and health care delivery-- and it just shouldn't be so damn hard. It's insane that we have to beg for resources to do this work.
- I remember as a young adult hearing the term. "The corporal works of mercy" and realizing that is what they had been telling us in Sunday School-- 'Clothe the naked, feed the hungry, visit the prisoners, bury the dead." All that stuff that would become so crucial to my professional life-- all of it was packed in there. I just had to know how to go looking for it.
- The thing that I would most like is a stance. A position. And to couch it in negative terms it's a position against leaving people out to dry, and without a safety net. In positive terms it is for solidarity, and for pragmatic solidarity specifically-- thinking about the material needs of others. I think material is an important thing to underline. Yes we all have spiritual needs and social needs, and we've talked a fair amount about them --but I am so struck by the material needs of some of the folks that I see, including those with wonderful spiritual assets, but they don't have tin on their roof, and their kids aren't in college, and their medical needs aren't attended to. So I am just asking for that stance -- that we say, "It's not okay to leave people out in the cold like that."
In case of interest:
- For those curious about Liberation theology and its relationship to the themes and underpinnings of Paul's work and philosophy, here's an excerpt from 'Paul Farmer: Servant to the Poor' [The book opens with a captivating description of the creation of the hospital garden in Haiti that Paul referenced so many times :)]
- A quick definition from the above book for those who may not be familiar with the term Liberation theology, "Liberation theology is a theological movement rooted in the social movements for freedom that arose in Latin America in the 1960s. Liberation theology seeks to interpret the Scriptures and the Christian tradition in light of efforts to overcome the scandal of poverty and oppression. Taking the view “from below”—that is, from the perspective of the poor—liberation theology attempts to identify the “structural sins” that create terrible poverty for billions of people in the world and contrasts this reality with the kingdom of God that Jesus preached. Liberation theology challenges individual Christians, the church as a whole, and even non-Christians to make a preferential option for the poor, to work towards eliminating unjust structures and conditions, and to build a more just world."
- And an excerpt from In the Company of the Poor, a book written by Paul and one of his mentors and friends, the Peruvian priest and PIH co-founder Father Gustavo Gutiérrez. The book explores their shared commitment to a “theology of accompaniment”—a lifelong practice of not only walking with people who are poor, but working to change the conditions that keep them poor.
- And for those interested in following the work of PIH, here's a link to their website.
"You will— you must— find out about the world’s wounds," Paul said to a graduating class 15 years ago, "My own guess is that poverty and powerlessness and untreated disease are hell on earth and that there’s nothing God-given about such conditions. They are man-given. And if hell can be created by others, rather than by some inescapable force of God or nature, we humans might just have a salvific role to play."
Words that feel particularly fitting in this holy season, as we come to the end of a year that has witnessed so much suffering, and also, so many moments of grace. May we each find it within us to play our salvific roles.
Pavi on behalf of the Awakin team
What are some of your golden threads Paul?
Service to others. There's one thread. And there's so much reward for that--it's a powerful thread.
When did you realize this was your thread?
My parents were extremely other focused. Even when we lived in a campground my unpredictable father was busy doing things for the others who lived there. By the time I got to Haiti, I was prepared to look for that thread. Haiti really marked the beginning of my adult life. But you're not prepared if you are not prepared--and so I would definitely credit my parents.
When did you go to Haiti?
I went to Haiti right after I graduated. I knew it was going to change me forever and it did. I am still working in the same parts of Haiti as I was in 1983. I had met Haitians glancingly growing up in Florida, as it was an area with a lot of migrant farm workers and I got reintroduced to that whole world of the migrant farm worker in undergrad at Duke, because that migrant stream on our coast moves from south to north. By then I was trying to be an adult in the middle of the wealth that is the American college campus-- the intellectual, and if we're lucky the moral wealth of college.
How did you choose Haiti?
Serendipity played a big role. In my senior year, I announced with gusto that I was going to apply for a Fulbright to go to French West Africa. There is no such thing as French West Africa but I didn't know that. I would discover it in time -- it would take me a long time. I applied for a Fulbright-- whatever led me to believe I was worthy of such an honor I don't know, but I didn't even get an interview. Haiti was Plan B. And that changed everything for me. So you have to be ready for the unknowable. I thought I was going one place, and I ended up in another. I have no idea why-- beyond things like White Privilege-- why I thought I was suitable for the task. But I am so glad that I did have that confidence and gladder still that I went. It is still changing my life.
Did you know then that medicine was your path?
Yes, but again I had no idea why I had that conviction. When I went to interview at Harvard Medical School of all places I am really glad they didn't ask me, "Why do you want to be a doctor?" I never ask applicants that question because I think to this day-- how would I have answered that? Whatever my reasons were, I grew into them. Back then I was 23 years old. I thought the work that we were doing in Haiti was just fabulous-- even though it wasn't --it was mediocre like much of it is. That's why I am not too judgemental of young people, even privileged ones. You have to go through these growing experiences, and just hope they are not in any way harmful to others.
Can you speak about the vastly different worlds you travel between, and the tension between the two, and what emerges when you move back and forth?
In the first decade of moving between Harvard and Haiti, I found myself bumping against a physical resentment. When I'd go back to the States and see the grocery store overflowing with everything you could possibly need-- a million brands of dishwashing detergent etc etc. That resentment was not a great thing to feel, nor a very useful sentiment at the time. As I got older I realized, we don't live in three worlds-- first world, second world, third world-- but in one world. So it's not that the intellectual or moral underpinnings of my resentment faded -- on the contrary -- but it was no longer a personal dilemma for me. I came to regard the Haiti-Harvard circuit as very bracing, and it was one of the reasons why I was so enthused about my medical work, and so immune to burnout. I had this protection because of Harvard-Haiti. That resentment was fashioned into something more durable, more powerful. It grew into a hard resolve that sticking with something over time, and working with lots of different people was the way to make a difference.
What is your insulation against burnout?
I think I would be at risk of being an automaton like everyone else but when you go from the Brigham and Women's hospital to a prison in Siberia that's a bit of a jump. So is going from being an undergraduate at Duke to being a caregiver in training at Harvard. I have been able to seize those calls to be present. I don't give myself any credit for that -- the drama of the change is important too-- it makes it difficult not to be present. So part of it is really just the mundane matter of variety. Anybody can get into a rut. Anybody is at risk of burnout. I know that I am too, but the variety of my practice, just the geographical variety, inspires me. Finally getting to West Africa and getting to know the people and the place and its history, was a major dose of variety in my life. Yes Ebola was different from some other pathologies I've seen but it wasn't so much the illness-- it's more about getting to know the people. It doesn't always require going to a new place. Going back to Haiti after being out of it because of COVID-19 will be another chance to renew those, well-- vows-- I might as well say that.
It's not a superpower. Anyone can have the conviction and resolve to stick with something over time.
You have to pay attention to the limitations of your ability to get to know people in the way you would like. I'm not always going to be able to do the things that I like to do most -- which is to explore human difference, and get to know people in very different settings. They don't have time to make me an anthropologist of a Siberian prison. I knew it wouldn't happen in West Africa as it did in Haiti. I lived in Rwanda for a decade, two of my kids were born there -- but I don't have that level of familiarity with Rwanda that I do with Haiti-- and I feel like I am now trying to explain a superpower that I just said I don't have. Being present to people is the key in my view -- it is the key.
One of the things that stuns me is why we would waste any time in our youth, not callow youth-- I mean anyone under 50--why would we waste time pretending we know things or can do things for reasons other than the real ones? Why not reveal trade secrets? I tell my students all the time if you can't write well, write s$@! and then fix it. That's what I do. I share my crappy writing with great writers knowing that I will learn how to make it less crappy. And the way I link that to the superpower of presence is that anyone can take that counsel right? Be present to other people --understand that your first efforts, and your second, and fifteenth will be imperfect, but just keep plugging away at it. Anyone can do these things. I know that we often do not, I often do not, but anyone could. I went to the squatter settlement in central Haiti in May of 1983 and I am still going to that same place. That's not just someone looking for the new only-- it's also about paying attention to how things change over time when you apply yourself to them.
Especially for me as a doctor the thing that you really helped illuminate is the social determinants of disease, the adage that in integrative medicine zipcode matters a lot more than genetic code...
This is why all medicine should be integrative. When you are present you are being bombarded with information that we can't possibly take in. It's too messy, too overwhelming, but in time it will penetrate and we will understand how to integrate it. I was lucky enough to study anthropology and medicine at the same time so for me they have always been really integrated as a vocation. But it takes a long time for so much of this to percolate and the 'this' I am talking about is social context. With a growing awareness of how social determinants work -- one of the troubling side effects is that we can fail to pay attention to the very downstream trouble -- like Ebola, a gunshot wound, respiratory distress with COVID 19. As people wake up to learning more about causation, and downstream and upstream causes, we have to remember to take good care of each other in those moments.
And that is something I try to get at in this book. My mistrust of public health isn't born out of anything other than the way it is practiced. We have to be careful not to forget that some people are already critically ill. In the US we tend to remember that. But in much of the world we shut out the ongoing suffering of disease and injury in people living in poverty and speak only about their prospects in the face of prevention.
The people most at risk of having their voices shutout are the critically ill and injured who live in extreme poverty far from affluent areas, and I was very mindful of their plight, I learned to be in Haiti. When someone has leukemia in Haiti, or bipolar disease or some rare malignancy --they are going to be asking for care just as much as anyone on the Harvard side, or in SF or Boston. I feel like I'm preaching now. Sorry.
No. You were not preaching. What's hard is being present to the suffering. We have a tendency to retract because it is too much. What I am hearing from you is just this simple act of being there and being present with it begins that moment of healing.
I think there is no question that it begins there. And it doesn't have to be sustained. Of course we'd love to be paragons of virtue but no one can sustain that kind of exposure to suffering, and happily it doesn't have to be prolonged so much as it has to be sincere. And that's the real beauty of this work-- it never fails no matter where you are. Every single time it is possible to make human connections. They may be glancing and brief, and they may not be accompanied by deep cultural insight, but they are there, and you can see them. I feel so fortunate to have discovered this - thanks in many ways to Haiti. I knew that that connection was real, and I thought it could be permanent-- and it's been long lived certainly. And it's happened every time in radically different cultural settings. I think that's just such a precious insight.
PIH is in 12 countries including Navajo Nation. The complement to the new is to entrap yourself into responsibility -- not responsibility for other people's agency, it's not like that at all. It's asking, "Are we part of the human family?" And we've always known people who say yeah we are part of that human family. And the 'we' here is not a bunch of white people from Boston. Our work in Haiti is run by Haitians, and Rwandans in Rwanda and so it is around the world, but that connection implies some responsibility as well. We called it Partners in health by the way, to fight the lack of partnership that too often afflicts NGOs and charities. We want to be on the other side of that ledger.
Can you give us a snapshot into the history of this region you wrote about in 'Fever, Feuds & Diamonds'?
Last year I sent this book to Tony Fauci and he read it and complained that the printout was five inches thick, and that the history section is too long. If anyone has had a complaint it's that the history section is too long. The way I think about it is-- this wonderful treat that I have described of getting to know people in their hour of need -- treat isn't the word-- it's a deeply rewarding gift, What is the price of admission for that gift? I went to Rwanda for a decade and knew it wasn't my turn to be an expert on Rwanda, and so too in West Africa. I knew I wasn't going there so I could enjoy yet another dose of some place new. The history part for me was the price of admission for the kind of intimacy and connection I value. After the first year when so much of my attention and everyone's attention was rightfully on clinical services and responding to the crisis in front of us-- I knew I was going to go deep, and because this was the very place I wanted to go as a 22 year old, I could at least say the depth of my desire to know the place was deep. I knew that West Africa was the epicenter of the Atlantic world, on both sides of that great ocean- it is the place that tied us all together. North America, South America, Europe and Africa are bound together in many ways because of this connection to West Africa. I knew that but I didn't know any of the riveting details, and I wanted to go deep there. What's the price of admission when you are carrying people in their darkest moments? My price in any case was learning about those ravages and laying them out on paper.
Just to give us a little context this was between 2014 and 2016. 99% of the cases were in this region. 27,000 cases roughly with 11,000 deaths and with that there was also fear. People are running the other way and you're trying to get your compadres to go into the center of what's happening. What was it about the region? Why that region?
It's a clinical desert and a public health desert. A region laid low by war --the ravages of history are important to understand -- catastrophic civil war was on top of the neo-liberal agenda that squeezed resources out of health care and education. The British were there from the end of the 18th century, and they left in 1963. When they left they had not founded a single medical school or nursing school, and they had also banned black doctors from the colonial medical service. So the writing was on the wall early on. That could have been corrected after colonial rule-- but even if they had had good leadership--with what assets and resources? And they didn't have the most dedicated and committed leaders. It had been decimated. And by the time Ebola rolled around, without the staff, stuff, space and systems you can't do the caregiving work that would save lives, or the caregiving for burying the dead safely. The surrounding countries are less of clinical deserts than Sierra Leone and Liberia. In 38 years of doing this work in clinical deserts I have never seen anything quite like it-- a desert so desiccated. Liberia which is the oldest independent country on the continent according to many -at the time that Ebola hit they had 50 practicing physicians in the country-- which would be the equivalent of half a dozen physicians in Boston. So it is really desiccated.
Can you speak about the tension between containment vs care.
There is an idea I am familiar with, but I hope I never become accustomed to it--the idea that prevention is for poor people-- not care. I'm overstating it -- but you remember from the beginning of the AIDS epidemic, the most heavily afflicted continent was Africa-- the claims made then were that it wasn't cost-effective, sustainable, feasible, prudent, effective, or sensible to treat AIDS in Africa. And looking under colonial rule at epidemics for which there were agreed upon therapeutics or preventatives like vaccines it was the same story--of control over care. That's not the story that we see in the US. Here we see a containment nihilism, where people are giving up on containment. But that's not what we've seen with cholera, ebola, chikungunya, and AIDS. I was fighting against the notion that we would not deploy the basics of critical and supportive care to save lives in W Africa-- and that includes simple things like IV fluids. And if you've been paying close attention to other epidemics - Ebola, cholera etc you would have seen this played out in Yemen, Haiti-you can go through the list.
"Sorry all you need is oral rehydration salts, even though you're vomiting." You see that once and you don't forget it. You see it several times and you develop a real animus. And I have that animus.
I am upset by that logic.
Two people you dedicated the book to who came down with this infection. Could you share a little bit about the stories?
It was very difficult to write about Ibrahim and Yabom. Ibrahim was 26 when he fell ill with Ebola and lost over 20 members of his family. That was a new experience for me. I didn't know other patients who had lost so many family members to one pathogen. Yabom was 38, she was a young mother and spouse when she fell ill, and she lost children, her husband, her mother. I met these people at their lowest point. A real friendship came later as the real Ibrahim and Yabom came out of their grief. But their stories were so overwhelming.
It's embarrassing to confess that it wasn't until a month or two into the experience in Sierra Leone that I realized that every single adult patient we saw had also survived civil war. In addition to illness they were dealing with their own personal traumas, and stories of loss. It became something of a nightmare, particularly the Yabom interviews. I found myself planning for ways to not interview Yabom picking up where we left off. There was plenty of other work in that first year and I foreclosed-- I am not sure I even understood it that way then, but I foreclosed a lot of discussions with her just by being busy with other work, some of it involving her. When her vision started to fade for instance, we were like, "Oh no! A classic complication of Ebola --we should have prevented that!" So there were lots of reasons not to talk about the loss of her husband, and mother and I cooked up a lot of excuses. Am grateful that she shared those things with me, grateful to my friend, coworker and former student who helped me through those interviews. She speaks many more languages than I do, so I had to have some help, and some of it was also psychological and emotional. I often didn't want to hear these stories on my own. It was a grueling process.
I got a message from Yabom yesterday. I know she and Ibrahim understand my gratitude. I know they approve of the work. But I hope readers understand how difficult it was to extract the information, and that probably is the right word. What doesn't come through in what I've shared here is how much joy there is in this work. We've had some wonderful times together already and they continue. That sounds like a hastily tacked on addendum. I reread the book (something I don't usually do), and I am aware that it comes across as a dark set of chapters-- but there was so much joy in this work, and there is a lot of joy I derive from my friendship with these two and I know they feel the same way.
Can you share a story or two from the field?
One of the things that I've enjoyed -- you know how people will tell you you need cultural competence? That's an absurd idea. I know anthropologists who have worked for 40 years in one place and who are not culturally competent in discussing the language and culture of the place. Why would we think we could become culturally competent in the course of medical school or nursing school? So I push instead for cultural humility. When you have that going in you're going to learn all kinds of things. Like when you're interviewing someone for the 50th time preferably over a meal and they mention their sister, and you say, "I didn't know you had a sister!" That happened over and over again. All of these kinship stories start to come out of the woodwork. We break bread a lot. In fact, we decided we were going to get together regularly for meals. They told me, "They are not going to let you have a meal for Ebola survivors at the Radisson!" And I said, "Oh they definitely will, if we pay them." And we did have a meal for Ebola survivors at the Radisson. And we still do to this day. It wasn't the Radisson back then, it was bought by them or whatever they do in the mysterious world of hotels.
Is there a place where you feel most at home?
Probably my garden in Miami or Haiti. They both have koi. I have to have koi. In the hospitals too. They have koi ponds in SF so we should have them in Haiti as well. And we do. You have to have koi for a garden and you have to have a garden for a hospital.
How do you sit with your own privilege in the work that you do? I hope that this question doesn't come off wrong for there are no words for the love and dedication that you have poured into the work that you do.
I was giving a talk at Vasser a few years ago. I have a number of friends who have worked there and one of them is a history professor from Sierra Leone. I was just getting to know him (and would later ask him to help me with this book and invite him to teach in Rwanda.) He was emceeing a Q&A session with a bunch of students, and one of them asked, "Why did you have the conviction that you could go to Haiti and make a difference?" I did my best -- it was a long session and this was hours into the discussion, but I realized afterwards I didn't even mention white privilege in my answer. I'm sure my answer was fine, but I thought I'm not going to do that again --I'm not going to forget to have that mindfulness bell ringing where I acknowledge my own privilege.
I have a deep debt to the Haitians. If you go deep into Haiti and if you rarely go to the capital you're going to see a different side of Haiti and a different set of protagonists and antagonists will emerge. Because structural racism and structural inequalities are real, and the way I do it is to try and keep myself mindful. Writing the history section as I said was the price of admission for the intimacy that one gets by giving a caregiver, whether as a physician, nurse or mom-- and it's part of the price to acknowledge white privilege and male privilege. I am nowhere near done with that exercise. I think it's better to keep it going as a conversation, at least with yourself, but preferably we are also talking about it with our students, our colleagues, our family members. There has been more discussion about it this year than any time in the past so I come at it with a great deal of optimism as well.
What are some of the universal principles around healing that you've observed in the course of your work?
The primary unit of caregiving is the family. That's not something you learn in medical school. When you talk about caregivers you're usually talking about nurses, doctors, maybe therapists, social workers-- but the primary unit is the family. And in a lot of places I've worked the secondary unit of caregiving is traditional healers. I don't regard them as the competition but our coworkers and finding ways to work together has been a universal constant as well -- even in the clinical desert where you are trying to put in place a safety net. That's another universal constant: The need for safety nets is universal. Even affluent countries that don't have them are going to suffer-- as we are now in the midst of the COVID 19 pandemic here in the United States. I could go on and on about things I think are universal, which by the way, is not recommended in anthropology, it's kind of the bugaboo.
But I don't have those reservations. Here's another universal principle: Anywhere you go, if you go as a caregiver, you will be recognized as a caregiver and welcomed. In a prison in Siberia, in a Navajo town, in a squatter settlement in Lima or rural Haiti --it's the same thing. Of course there are exceptions, but they are rare. Another universal principle: When people are ill or injured what they are looking for is care. The kind touch, love, support--they are looking for care. This means something really important in the middle of an epidemic--if you favor control over care, you're going to see people recoiling. Other than those four or five principles everything is so varied --so I open myself up to the variation. But I do think there are universals as well.
How do you hold senseless suffering?
A big part of the secret is of course community. Asking, "What's your community?" Mine is Partners in Health. Even in my academic community-- the same one I have been in for decades-- it's people who support or work with PIH. My former boss and mentor likes to say that now I'm his boss, which is technically true, but again this community is part of that broader caregiving community. I don't work for PIH. I'm a volunteer. I have a day job and in that day job, my boss, my students, my colleagues, are part of the secret. They all shore you up when you need it. And that's the #1 secret --none of this stuff is individual work, it is always collective. And if it's got your back you know it. Also -- like anybody else I have hobbies. Mine is gardening, and although other people benefit from my hobby -- my staff, my patients -- I do it for me. I can spend an hour trying to pot up an orchid or trying to put a bromeliad in the ground. I must need it or I wouldn't do it. When we were living in a campground my parents let me make a koi pond out of cement. We were living in a bus and they still let me do it! I even had an aquarium in the bus. All to say wherever the instinct comes from, it goes deep. It's primordial.
What's your insight into the epidemic of disbelief that we seem to be experiencing here?
I do think that we see patterns again and again-- and one of them is that cognitive change is probably not required to stop an epidemic. Why did the Ebola epidemic stop in upper West Africa? It did stop, but not because we lectured on the perils of eating bush meat or taking care of the sick. We have no evidence that our radio shows and information spots worked --on the good side that means we don't have to make Americans a bunch of vaccine experts between now and wide uptake. There's no evidence that in rural West Africa Sierra Leone, Liberia and Guinea that people understand how a vaccine works So I am not one of those medical anthropologists or physicians who thinks everyone should take a crash course for these vaccines to work. But what we do need is to have enough trust that there will be uptake without mandates, because I don't think we are going to get mandates for vaccines--maybe for health care providers-- but right now we are nowhere near the doorway of having not enough demand. We are going to have plenty of people taking the vaccine and we need to swell that demand-- but not by hectoring people. We need to acknowledge the mistrust in communities of color. Should someone be able to graduate from medical school in the US without knowing what Tuskeegee is? I don't think so. I think we have to understand what makes people distrustful, but we don't need to do all of that between now and when we roll out the vaccine--thank God! We need to really focus on making sure we can meet demand, and that it is done fairly.
How do you practice self-compassion?
Gardening. Buying myself very nice plants and trees-- or getting other people to buy them as the case may be.
Sometimes you need to know when to shut down. Allowing yourself to be looked out for by other people. And in a strong community you look out for each other and that's one of the most important parts of self care.
Any spiritual or religious underpinnings in your upbringing?
Not really. Nominally, I was brought up in a Catholic household. The framework that I cherish to this day, I came across in adulthood working in Latin America and reading about Liberation Theology. I found and still find it powerful as a corrective, as a call to action and I find it powerful spiritually--I have no trouble saying that. But my parents held religion at arm's length. But as I said before they were extremely other centered.
I remember as a young adult hearing the term. "The corporal works of mercy" and realizing that is what they had been telling us in Sunday School-- 'Clothe the naked, feed the hungry, visit the prisoners, bury the dead." All that stuff that would become so crucial to my professional life all of it was packed in there. I just had to know how to go looking for it-- and my parents did certainly push for those corporal works of mercy.
Erroneous assumptions you've encountered along the way?
The idea that there is a split between prevention and care-- where does that come from? Why would that be a good thing? Why wouldn't we want to integrate them, when after all human flesh is heir to all these infections and injuries? That may seem overly technical. I think a lot of us in public health and global health equity are very much intimidated by the voices of development economists who will say, "That is not cost-effective, feasible, sustainable," a bunch of jargon and buzzwords that are not always backed up with data-- so why would be back them up with conviction?
I've gotten more confident with time. I can say Rwanda and Haiti don't have a lot in common culturally or linguistically but they have a lot in common structurally -- they are both poor and agrarian and settings in which there has been a lot of conflict. Those are important similarities and I've gotten more confident about asserting that. And there is cause for confidence -- for example you can read an X-ray in Siberian prison as well as you can in a Peruvian prison. You see enough of the same problem again and again, then you can get good at managing it. Of course you can fall into traps too but these convictions are helpful as the years go by.
What kinds of healthcare is sustainable? How can ordinary people help?
That's the question as we should hear it. It's a sincere question -- what kind of healthcare is sustainable? Very often you hear that question with an animus. A negative impression. Just the tone itself tells you that the question is not always posed in the same way. I would say this- we don't have any evidence so far that we are pushing too hard to sustain unsustainable healthcare anywhere. We know places with a lot of waste- the US is a classic example. We are putting 17-18%of our GDP in healthcare-- and for what kind of return? But that's not the same as saying we are trying to put too many resources into healthcare here. It's saying we aren't doing a good job of it, we don't have the systems set up correctly, and the incentives are all misaligned. So I would say as a species we should take a very different approach to this question, and say, "We don't have evidence that we are putting too much of our resources into education or healthcare-- and when we are, we will let you know." Even in Europe, and US and Canada where we put a fair amount of our resources into healthcare and education, we don't have any evidence that we are getting near some tipping point where it is too much. And in clinical deserts I think we should proceed as if we are nowhere near reaching a saturation point -- we are a long way from overwatering them. I'm not sure I've ever seen a clinical desert overwatered anywhere. Rwanda is a very impressive example because after hitting rock bottom in 1994 there are now settings in all of Rwanda where you can say the declines in mortalities seen in the last 10-15 years are the steepest declines documented anywhere and any time in human history. So even if they are hitting 20% of their public budget there is no evidence that they are putting too much into healthcare.
What are you leaning into in this phase of your journey?
I am leaning into screaming and yelling that it should not be so hard for us to rebuild or build for the first time these health systems. And I'm speaking as someone who works with PIH here. Why should we have to scream about this year in and year out? We have plenty of reminders from epidemics and catastrophes and now we have a pandemic. I think it should be easier for us. People are saying we will help build the system and strengthen it and put in place public safety nets, hospitals, clinics, health insurance schemes, and it's a joy to do that work-- but it should not be so difficult. We still are fighting for scraps to build proper health security. Health security is not going to come out of the kind of security you get with armed peacekeepers after a conflict has ended. It's going to come with a safety net, and particularly with insurance, education and health care delivery-- and it just shouldn't be so damn hard. It's insane that we have to beg for resources to do this work.
What worries you and what inspires you as you consider the future?
The inspiring ones to me are the students-- whether in Haiti Rwanda or Harvard -- it's a very reassuring thing -- when I look at what I knew when I was 22 and compare it to what they know about pandemics, social safety nets and racial disparities. They know a lot more than I did at their age. What keeps me awake at night -- again--it is insane that someone like me has to beg all the time for resources for this work -- that keeps me up at night. We should never lay off a single person involved in this work -- to shrink the work because we can't find the resources? That is insane.
What I am taking away from this conversation is not just this big, fat dose of hope and inspiration but something that feels very pragmatic that I can use in my daily life when I am feeling that sense of paralysis when some of these problems feel so big so global -- that it's really as simple as taking the next step of connecting with another human being. Especially the vulnerable. Acknowledging my own privilege, having cultural humility, meeting people with sincerity, remembering I am not alone, and renewing our most intimate vows-- the vows we took knowingly or unknowingly. How can we as the ServiceSpace community support you Paul?
First of all I feel that the ServiceSpace community is already supporting our work, and indeed the reason I'm not pulling out what little hair I have left is that we do have an audience here. I want to stay part of this community. I will cling to it as well. And the thing that I would most like is a stance. A position. And to couch it in negative terms it's a position against leaving people out to dry, and without a safety net. In positive terms it is for solidarity, and for pragmatic solidarity specifically, and that is when we think about the material needs of others. I think material is an important thing to underline. Yes we all have spiritual needs and social needs, and we've talked a fair amount about them --but I am so struck by the material needs of some of the folks that I see, including those with wonderful spiritual assets, but they don't have tin on their roof, and their kids aren't in college, and their medical needs aren't attended to. So I am just asking for that stance -- that we say, "It's not okay to leave people out in the cold like that."