Dr. Paul Farmer, co-founder of Partners In Health, an organization that builds hospitals and provides heathcare to countries afflicted by poor health conditions, attends to one of his patients in rural Haiti.

Dr. Paul Farmer, co-founder of Partners In Health, an organization that builds hospitals and provides heathcare to countries afflicted by poor health conditions, attends to one of his patients in rural Haiti.

Diane speaks with renowned physician and social activist Paul Farmer. In his latest book, he encourages young people to tackle the greatest challenges of our times, from global health and poverty to climate change.

Guests

  • Paul Farmer co-founder of Partners in Health and chair of the Department of Global Health and Social Medicine at Harvard Medical School.

Read An Excerpt

Excerpt from “To Repair the World: Paul Farmer Speaks to the Next Generation” by Paul Farmer. Copyright 2013 by Paul Farmer. Reprinted here by permission of University of California Press . All rights reserved.

Transcript

  • 11:06:56

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Former President Bill Clinton says the work of Paul Farmer should be recognized by a Noble Prize. The medical anthropologist has dedicated his life to making healthcare a human right. And now his book brings a new generation into the fight for global health equity.

  • 11:07:21

    MS. DIANE REHMIt's titled "To Repair the World." Paul Farmer joins me from a studio at Harvard University. You're welcome to be part of the conversation. Give us a call, 800-433-8850. Send your email to drshow@wamu.org, follow us on Facebook or send us a tweet. Good morning to you, Dr. Farmer. Thanks for joining us.

  • 11:07:51

    DR. PAUL FARMERThank you for having me, Diane.

  • 11:07:53

    REHMGood to have you with us. I know how busy a man you are. Is it true that you're correctly living in Kigali, Rwanda?

  • 11:08:07

    FARMERWell, I've been between Harvard, Kigali and Haiti over the past few years.

  • 11:08:14

    REHMTell me about what you are seeing in Haiti most recently.

  • 11:08:21

    FARMERWell, I just got back from Haiti this morning and so I can, what I just saw was a new teaching hospital that together with our partners in the Haitian ministry of health and partners from all over the world, a lot of them from Partners in Health, of course.

  • 11:08:42

    FARMERWe opened this beautiful new teaching hospital and it is spectacular and it is a design to actually address those healthcare disparities you mentioned in your intro. So I've seen a lot of good things happen recently and that one most colossal among them.

  • 11:09:01

    REHMYou know, it surprised me when I saw films of that hospital because what we have seen most recently in terms of photographs or films of that country has been the ongoing poverty, has been those living still intensities and here in the midst as you just said, this gleaming new facility.

  • 11:09:38

    FARMERWell, it is a contrast experience because that hospital is designed to take care of the very people you mentioned. Those who are left behind by progress or are still facing extreme poverty and illness at the same time and, you know, we have a long way to go and we don't delude ourselves into thinking that a hospital or any other healthcare delivery institution is going to singlehandedly lift people out of poverty.

  • 11:10:07

    FARMERAt the same time, we believe that it can, an institution like that and the teaching that can happen inside of it can help break that cycle of poverty and disease that we see in images very often from there.

  • 11:10:20

    REHMHow was the money was raised to build that facility?

  • 11:10:26

    FARMERThe money was raised by private donations from people across the world especially the United States, some within Haiti as well, from companies and corporations that donated in kind. For example, the information technology, the IT backbone of the hospital from Hewlett-Packard etc. But there also union laborers from the electrician's union here in Boston, painter's union, carpenter's union who donated their time and skills not just to build that hospital but also to train Haitians how to learn these crafts, these trade crafts.

  • 11:11:12

    FARMERSo it really was a teaching hospital all through its construction as well and not just now that it's open. And again, the other thing I'd add is these were private donations but it's built as a public hospital.

  • 11:11:26

    REHMAnd how many U.S. physicians, how many Haitian physicians will be involved? Or put it more broadly in terms of employees themselves.

  • 11:11:41

    FARMERSure. Well, we've been working in Haiti for almost 30 years and our M-O has been to have the employees of Partners in Health and its sister organization in Haiti, which is Zanmi Lasante, be Haitian. So that's been another, a major part of any success we may have had is been by focusing on job creation and local capacity building.

  • 11:12:06

    FARMERAnd we've taken the same model to Rwanda. You mentioned Rwanda in your intro. The last 10 years, Malawi, Lesotho, everywhere we work, in Peru etc. This teaching hospital follows that general pattern but brings in subspecialists in fields of clinical medicine, nursing, hospital administration and some of the maintenance of the complex systems in a hospital has brought in people with that expertise if it doesn't exist in Haiti.

  • 11:12:40

    FARMERSometimes the expertise is brought in by members of the Haitian Diaspora who are coming back to help on projects like this. But it's still going to go in the same direction of local capacity building and creation of possibilities to provide high quality medical services by Haitians for other fellow Haitians.

  • 11:13:02

    REHMThe goal implied in the title of your book seems pretty lofty, "To Repair the World: Paul Farmer Speaks to the Next Generation." Talk about what you mean by repairing the world.

  • 11:13:26

    FARMERWell, at first, I feel like I should apologize if the title seems a little over the top. But it's meant sincerely, the world is, you know, a broken place in many senses and anybody who looks back on the history of our nation or any other knows it. I mean, again, I've worked in places like Rwanda, in Guatemala after a brutal civil war and genocide.

  • 11:13:56

    FARMERIn Peru at the tail end of a civil war and I've had the privilege of being in Haiti for all these long years and also in the United States with people who are displaced by these large scale social forces and historical events that you could see in Boston just as in Navajo Nation.

  • 11:14:16

    FARMERSo I don't think broken is the wrong metaphor but it also seems imminently possible to repair brokenness or make amends for it. And in fact, do a better job thinking about equity just as, even in an arena such as clinical medicine. We can do a better job and so that was the aspiration.

  • 11:14:42

    FARMERThe part about the next generation of course, you know, I'm a teacher, I'm speaking to you from Harvard Medical School, and that's how we see a sustainable future is working with the next generation to talk about not only what we've learned but errors that have been made in the past, mistakes that have been made in the past and to try do a better and less repetitive job. That was the basic thinking in collecting these essays.

  • 11:15:11

    REHMYou talk in these essays about health as a human right and you say it's been plagued by failures. What do you mean?

  • 11:15:26

    FARMERWell, I can certainly speak of personal failures and did on Sunday at this great celebration in the town of Miabella. I just remembered three of the young people that I had worked with when I was a young man in Haiti in the early and mid '80s. We had started a small group to work on a community health project and there were six or seven of us and within a few years three of that group were dead.

  • 11:16:00

    FARMERNone of them saw 30 years of age. One died of infection after childbirth, another cerebral malaria misdiagnosed as a mental illness and a third died in great pain of a perforated ileum after getting typhoid. So that's like half of our team so when I think about failures I do think about our own failures, mistakes that are made and I think that we can't say that the idea of health as a human right or these basic services, clean water, for example, as a right.

  • 11:16:39

    FARMERIn no regard has any of that been an unqualified success, not in the countries where I work including my own. And there are other paradigms beyond the right space paradigms that are important too. And they also support the notion that investments in these basic social services like healthcare and education will yield development, stability, safety etc.

  • 11:17:05

    FARMERSo I think the rights paradigm is important because it reminds us to think hard about social protection for the poorest. Because if, you know, people say it's not a feasible or cost effective to provide care for the most vulnerable and the frailest then we have to go back to these rights now.

  • 11:17:25

    FARMERI listened to the end of your last show and heard people talking about community based care and home based care for the elderly, the frail elderly, in this country. We've got a long way to go and we've actually learned some things in places like Haiti and Rwanda that could help us move towards the aspiration of the right to good healthcare here as well.

  • 11:17:46

    REHMAnd yet here in the richest country in the world, there are many without any health coverage whatsoever. The president's plan for overall healthcare has finally passed in a much reduced form and yet there are still those working to overturn it. That, many believe that healthcare is a personal, individual responsibility and that the government itself should have absolutely no part in it.

  • 11:18:30

    REHMSo as we talk about healthcare around the world we also have to talk about healthcare in this country. Paul Farmer's new book, "To Repair the World." Short break here and right back.

  • 11:20:05

    REHMAnd if you've just joined us, Paul Farmer is co-founder of Partners in Health. He's also chair of the Department of Global Health and Social Medicine at Harvard Medical School. He's just written a new book. It's a collection of essays titled "To Repair the World: Paul Farmer Speaks to the Next Generation." And Dr. Farmer, I know that you established Partners in Health -- you co-founded it back in 1987 when you were still a student in medical school.

  • 11:20:52

    REHMOne of our emailers, Christopher, says, "Paul is a hero of mine. I've read much of his work. At times he seems to struggle between anger at the structural aspects of poverty and the opportunity to provide health equity. I'd like to know what motivates him to do this work and the mixture of positive and negative experiences." Dr. Farmer.

  • 11:21:29

    FARMERWell, thank you, Christopher, for the question. I mean, the joy and positive parts of this are pretty easy to -- and pretty straightforward to understand. When you can deliver effective quality health services to people who are facing illness or injury, you -- these days you can get really get results. People get better.

  • 11:21:58

    FARMERAnd, you know, I certainly -- as someone who has been here in Boston for a long time, I can't help but think, and said so in Haiti this weekend, that in the Boston Marathon bombings nobody who reached a hospital died. And that's because we have -- even with all the deficiencies of our national health system, we have excellent teaching hospitals and some safety nets that could move the injured very quickly and efficiently to hospitals, like the one I trained and work in, the Brigham and Women's Hospital.

  • 11:22:38

    FARMERAnd that -- there's a -- and even in the face of tragedy and illness and suffering and pain, seeing patients receive good care and consolation and expert mercy is very uplifting. I can't think of anything more satisfying that just being in a modern teaching hospital in the middle of central Haiti, the same town, by the way, where those three young people I mentioned earlier had lived and died.

  • 11:23:08

    FARMERAnd, you know, I don't know how useful anger is or any other emotion but I think it is outrageous that there are people in the world today, in fact, hundreds of millions of them living on, you know, such tiny amounts of money. Living and dying, not having access to education, to a primary, secondary or tertiary education, not having access to clean water. I think it's outrageous. It's distressing. It's not the way things should be. It's something broken that needs fixing. And cultivating joy and satisfaction in the face of adversity is a very worthwhile pursuit, I have no doubt.

  • 11:23:56

    FARMERBut I think there's also an illusion that these are -- that an earthquakes for example in Haiti, that it's a natural disaster. It's also a social disaster. I mean, nobody believes really, in the United States, that Katrina and what it revealed was just the result of bad weather. And -- Hurricane Katrina I'm referring to. So that's why we should have some high emotion around these issues as well because they're really social artifacts as much as anything else, and we can fix them. That's the good news, getting back to the positive joys.

  • 11:24:32

    FARMERI don't mean to get too philosophical on your listening audience, but I think it's a natural -- at least it feels natural to me -- way of shuttling between optimism and pessimism, you know, and tough analysis and intervention that is very satisfying when it's effective.

  • 11:24:53

    REHMHow do you take care of yourself and those around you when you're in the midst of an area that may be populated so heavily by those who are really desperately ill?

  • 11:25:15

    FARMERYeah well, that's a great technical question. And, you know, just to get very specific first, the nature of threat to the staff is based on what's going on obviously in the clinic or hospital or village or town or squatter settlement, whatever it may be. The biggest problem that we face in that regard is tuberculosis. Not just in the southern regions of Africa, but even in our work in Haiti and Rwanda and in Siberia and Peru.

  • 11:25:52

    FARMERWe're working a lot in prisons, hospitals, clinics, institutions where you really need to address that risk, which is often invisible because it's an airborne disease. And you can't really tell when someone has been infected. And the best way to protect ourselves as providers -- I think that's what you meant by the question...

  • 11:26:15

    REHMYes.

  • 11:26:16

    FARMER...is to make sure there's good infection control for everybody. And that's not easy to do. In this new hospital what we've done is to bring in some methods that are fairly straight forward. For example, having open courtyards, decreasing the number of walls and windows, having air move through. And then but also overhead fans that move the air, ultraviolet lights that kill the organism that causes tuberculosis. And in some of the areas of the hospital which need to be closed, like an operating theater -- the block of operating theaters, with filters that pull out the air.

  • 11:26:59

    FARMERAnd so those are a mix of what some people think of as high tech and low tech interventions. And we've been able to do that though in Africa as well, in the places we work.

  • 11:27:08

    REHMBut now backup to 1987 and the founding of partners in health. What did you hope to achieve by founding that organization? And how far do you believe you've come?

  • 11:27:31

    FARMERWell, thank you for asking that. I mean, we were mostly young. I was 27 in 1987 so, you know, you look back -- and we did -- and say, well what did we define as our mission statement? And I think our mission statement is pretty cool. It says that we're going to make a preferential option for the poor in health care. That was a notion borrowed from theology. But it also says we're going to do that by linking elite medical centers, and we changed that to academic medical centers to the problems that we're seeing in places where there aren't modern medical facilities.

  • 11:28:13

    FARMERAnd again, this weekend is an example of that. It's not just a hospital in Haiti. It's a teaching hospital. It links places like the Harvard teaching hospitals, including the Brigham, which I mentioned, to central Haiti and other universities. We've done that in Rwanda as well. So it's actually -- it was a pretty -- the mission was fairly specific. And how well are we doing? Well, I think we're meeting a lot of those goals. It's taken a long time, it seems to me, 25 years. And we're just one of many groups probably working toward this goal.

  • 11:28:50

    FARMERBut in the last few years alone we've seen -- for example, we've seen a lot of academic medical centers, for example, go with us to Rwanda to work with the ministry of health, to build medical and nursing capacity that just never existed in Rwanda, even before the genocide in 1994. I think the same thing is happening in many of the other places we work as well. So we don't -- we have a long way to go because we're interested in health equity globally, not just in one country or one place. But I think the people who founded Partners in Health, those who are still with us, are proud of progress made.

  • 11:29:34

    REHMAnd here's an email from Carol in Columbia, Md. who says, "If the goal is to keep doctors where they are most needed, what's to stop them from going to the U.S. or elsewhere as money and prestige tempt them?"

  • 11:29:56

    FARMERYeah, that's a great question. You know, a lot of people call that the brain drain, right, in medicine and nursing. And, you know, I was in Malawi in Lesotho in January and -- where Partners in Health is working again with the local health authorities. And people were saying, well there are probably more nurses in Manchester, England than there are -- Malawi nurses in Manchester than in Malawi.

  • 11:30:21

    FARMERAnd the brain drain, there's two ways to think of it. One is, how do you keep professionals from leaving their countries, which is not the way I would recommend doing it. Or the other way is how do you keep them where they're needed in their countries? A lot of these professionals have been trained on the public dime, you know, in Haiti, Rwanda, Malawi, Lesotho. And there's enormous need. And if they were to make a preferential option of the poor in health care, they'd stick right in their home communities.

  • 11:30:52

    FARMERBut keeping -- you know, preventing people from moving around freely is not the best way to do it. How can we keep them? Make sure they're paid adequately, that they have good working environments? You mentioned already, Diane, that, you know, there's enormous risk to health care workers from epidemic disease. And tuberculosis is the main one. How do we make sure that they're protected and safe in their work environments? And then how can it be a teaching and learning environment?

  • 11:31:21

    FARMERSo we've been focusing not on the pull forces, to pull them back to or keep people in these working -- in these situations because the work is enjoyable and satisfying and uplifting and has joy in it. And let me tell you, when you're a nurse or a doctor and you're sitting in some, you know, poor quality medical infrastructure where the electricity's going out, you don't have internet, you don't have the medicines, it's dirty, it's stank, it smells bad and there are 200 people waiting in line to see you, nobody can take that for long. And it's not a way to deliver good medical care, And it's certainly not a way to retain people.

  • 11:32:01

    FARMERSo, Carol, I don't know if I answered your question, but we're very focused on creating good working conditions for young professionals, and the not so young professionals.

  • 11:32:08

    REHMAnd what does that mean in terms of the evolution of your own involvement in these various projects around the world? Are you constantly on the road? Are you staying in one place for months? How do you manage?

  • 11:32:31

    FARMERWell, I'm not necessarily doing exactly what I like the most, which would be sitting in place and providing care. I feel like it's my turn to actually try and create those kind of possibilities for many other people. So in other words, finding the resources and pulling people together to build health care institutions and health care systems occupies increasingly my time, as does teaching.

  • 11:33:04

    REHMIn other words, raising money.

  • 11:33:08

    FARMERRaising money and commitment also. You know, we talk about accompaniment in our work. It's not just money. It's long term commitment. And in Rwanda, for example, when I started there ten years ago, I spent a lot of time in direct clinical work with my colleagues, many from Partners in Health, some from the Rwanda ministry of health. And then the last few years have been more focused on understanding successes and failures that we've had in working with the public authorities to build health systems and just thinking about national health systems. It's not always the most enchanting part of the work for me but I think it's been very rewarding.

  • 11:33:51

    REHMAnd you're listening to "The Diane Rehm Show." I want to open the phones and take a few calls before the break. First let's go to Greenville, S.C. Good morning, Joey. You're on the air.

  • 11:34:11

    JOEYGood morning. I'd like to ask Mr. Farmer here what he feels about religion's role in health care and, you know, the challenges that come along in places like Haiti. And even here in the United States when we have such a strong tie with, you know, the right and the Republicans and Christians opposing health care, when if you really look at Jesus' ministry, for example, it was very much about compassion and helping people. What would you say to this?

  • 11:34:48

    FARMERWell, I think the word is roles, right? You said that yourself, Joey, that there's very disparate ideas about what the role of faith should be in attending to the kind of problems that we see. And when I say see, I mean see in a clinic if people are lucky enough to get in a clinic or hospital. But you see it everywhere where there's poverty and inequality.

  • 11:35:14

    FARMERI think, you know, the founders of the church you mentioned are pretty clear on that. That's where the whole term preferential option for the poor comes from. It comes from the notion that there are these so-called corporal works of mercy. They feed the hungry, clothe the naked, you know, visit the prisoners, etcetera. It's very -- pretty straightforward if you ask me. And so the idea of religion having a role to block those kind of corporal works of mercy and acts of justice, just -- I know why you call that religion. I mean, it's some other phenomenon that -- but I'm not sure that it squares with Christian theology.

  • 11:36:01

    FARMERI mean, I'm not that familiar -- actually "To Repair the World," the title of the book comes from Jewish philosophy and theology. But I think the ideas underpinning a lot of the religions that are really very clear on social justice for people who are poor, vulnerable, marginalized, you know, rejected, sick, injured. And that I think can be a great inspiration and is indeed to many who do this work. Many of them are inspired by their understanding of, you know, what the Good Samaritan did. He didn't go to help someone he knew. He went to help a complete stranger.

  • 11:36:44

    FARMERAnd, you know, I don't want to sound Pollyannaish or -- but that's how I read what religion's role should be, which is to support acts of mercy and justice.

  • 11:36:56

    REHMAnd just to elaborate, we've had an email from someone who says, "Repairing the world is a translation of tikkun olam, a Hebrew phrase that means repairing or healing the world, suggesting humanity's shared responsibility to heal, repair and transform the world." We'll take a short break in our conversation with Dr. Paul Farmer. When we come back, more of your calls, your comments. Stay with us.

  • 11:40:03

    REHMAnd welcome back. If you've just joined us, Paul Farmer is with me. He is joining us from Harvard University where he's chair of the Department of Global Health and Social Medicine. And the author of "To Repair The World: Paul Farmer Speaks to the Next Generation." Right now he's speaking to you. And if you have a question or comment, join us by phone, email, follow us on Twitter or Facebook. Let's go to Sarasota, Fla. Good morning, Cathy. You're on the air.

  • 11:40:51

    CATHYOh, I’m thrilled to be here. My question is this, you know, we talk about social responsibilities to the sick and the poor, admirable qualities and certainly qualities that come with the Christian religion, as well as others. And yet, we have politicians, especially on the right, who profess to be Christians, but they counter the needs of those most vulnerable in our country that it's socialism. And, you know, I think that's a poor excuse. You know, how do you counter that?

  • 11:41:35

    FARMERWell, you know, when I hear that I generally try to think why is someone saying, you know, what is this person's point? You know, I kind of actually try to think like a doctor more than anything else. What is the need of this person to say that? I mean is this someone who wants to have a discussion about how to deliver services to the vulnerable and the sick? Or is this someone who doesn't want to have that discussion and is really trying to cut off the conversation? I mean, you know, again, there's almost always some ideological posturing going on or points trying to be made.

  • 11:42:11

    FARMERYou don't hear those kinds of comments very much in a clinic, a hospital. I've never heard it really in Haiti, in the work we do. It's really -- or in Rwanda, Malawi, et cetera. It's more of a political and sociological discussion. I don't want to use cop-out terms. I'm just saying, usually people don't have any real clear of definition of what they mean by socialism.

  • 11:42:36

    REHMAnd just to follow up on that, here's an email from Susannah, who says, "My concern in accepting the premise that healthcare is a right, is that it seems to imply the corollary that health care should also be free. But if people start to believe that healthcare should free, think of the impact on healthcare providers. Will they become slaves of a sort or vastly underpaid non-autonomous workers? My personal belief is that this cost should be spread amongst all members of the public through sound tax policy, but it should never ever be promoted as free." How do you respond to that, Dr. Farmer?

  • 11:43:35

    FARMERWell, first of all, healthcare is never free. Right. It always costs something to deliver good services, just as in education or clean water, etcetera. And second of all, the emailer makes a point. She said that healthcare costs should be shared by all. That's called insurance. Right. And a regressive insurance policy says you're sick, you pay. And a progressive insurance policy says, you know, it's when you're sick that you shouldn't have to worry about how healthcare financing is established. That's not when you want someone like the--again, going back to the Boston Marathon bombings. You don't want anybody who's injured to have to worry about the nature of healthcare financing in the city of Boston on a day like that.

  • 11:44:27

    REHMAnd surely no one is going to ask on a day like that, when one's leg is partially or wholly severed, do you have insurance before I take you.

  • 11:44:42

    FARMERThat's right. And, you know, these events, like an earthquake or an attack like the one here, they're reminders of the vulnerability of all of us. And I don't think you're necessarily disagreeing with me, the emailer. I'm sorry, I didn't catch your name, but no one who really does this work or has to raise resources, find people to do it, ever really believes it's free. The question is, how should healthcare be financed? And there are many instances in which it's not wise at all to have the sick to pay out of pocket for their healthcare. I'll go back to the example of tuberculosis. Tuberculosis is an airborne disease.

  • 11:45:31

    FARMERIt's a public health threat. And guess who it affects most of all, the poor. So if you say, well, we know that healthcare isn't free. We know it costs money. And we're going to have the patients pay out of pocket when they're sick with tuberculosis, that's a recipe for failure. You don't find the patients. You don't diagnose them correctly. And you don't get them in care, nor do you keep them in care. So it fails on every front, patient-based financing of tuberculosis care. Again, same with AIDS. When AIDS surpassed tuberculosis to become the leading infectious killer of young adults in the world, there were no programs, no plans to have healthcare delivery available to the great majority of those who needed the care most.

  • 11:46:22

    FARMERThere was no healthcare financing scheme. And then came along some big programs. One of them from the U.S. government, which is called President's Emergency Plan for AIDS Relief. That's the largest intervention for global health history in the history of the world. And it made treatment available.

  • 11:46:40

    REHMIs it all, in your view, in the hands of politicians? Is it all going to come down to the decisions they make from the right, the center or the left about who gets healthcare and how much?

  • 11:47:02

    FARMERMy guess is that the majority of what comes to pass will end up being decided in policy circles, yes. There are community-based health insurance schemes, for example, we have been involved in establishing those with our partners in Rwanda. The great majority of people in Rwanda have community-based health insurance now, much more than a great fraction are insured in Rwanda than in the United States, which is pretty startling. But, again, that was linked to a nationwide policy that was rolled out on the district and village level.

  • 11:47:43

    FARMERNow, I'm not pretending to be an expert on health insurance schemes, but it seems clear to a physician who's interested in this question and working in several countries in the world, that all of those countries have had to face this question of how to develop policies, if they want to deliver even the most rudimentary healthcare services to the great majority. And I don't see any escaping it. And it often is in the hands of political decision makers. Of course, they're elected, so…

  • 11:48:14

    REHMAll right. And you mentioned earlier the Boston Marathon bombings. There has been a tweet from the Boston Police Department saying only that, "Three more suspects are in custody and more details will follow." Here's an email from Susan in Arlington, Va. She says, "I understand you have been highly influenced by liberation theology. Is that true and if so, could you please say how the specific aspect of that particular strain has informed what you do?"

  • 11:49:09

    FARMERWell, I mean, it is true. That's certainly true. And it's a very interesting question. You sound like an infectious disease doctor. How has that strain influenced you? Again, going to Haiti when I was 23 years old and seeing a lot of things that I had never seen before, having rarely been out of the United States after growing up in Florida, I saw a lot of suffering. And I mentioned already some of ways that touched all of us personally because of losing people that we worked with of eminently preventable or treatable disease and other misfortune and injury. And of course that would only occur more over the years, as one spends more time in settings that are vulnerable, you could see more of it.

  • 11:50:09

    FARMERI just found it very useful to me, this notion of a preferential option for the poor, which I had cribbed directly from liberation theology and specifically from the work of Gustavo Gutierrez, who I later met in Peru. He's a native Peruvian. And have become good friends with. We actually just finished a book together about this topic. But I would add one thing that illnesses also make a preferential option for the poor. You know, AIDS, tuberculosis, cholera, even, you know, cancers, diabetes. There's increased burden of disease, not just from infectious diseases, but from non-communicable diseases, as well, among the poor.

  • 11:50:56

    FARMERAnd that seems like perhaps an obvious point, but it was helpful to me to think that if that were the case, how could we direct more of our attention as a profession of medicine, nursing, et cetera -- most of our attention, in fact, to the poor? That's what a preferential option to the poor in healthcare means. So it is true, of course, partisan health is a secular organization, not a religious one. And many people, who are themselves, not interested in Christian theology or other kinds of theology, nonetheless, find themselves inspired by some of these notions of, again, preferential options for the poor and also what some of us have called structural violence.

  • 11:51:46

    FARMERThat is there's a kind of violence that you see in a genocide, like Rwanda in 1994 or the military coups that we've seen in Haiti and elsewhere we've worked or in the Boston Marathon bombings. That's event violence. Things, you know, blow up right in front you. And yet there are other kinds of violence, too. There is violence that people in living in poverty are marginalized by gender and equality or racism face every day. And it plays itself out in healthcare. So those notions have all been helpful to us as we try to understand our work, how effective it is or isn't, how we can make it better and also how we can stay engaged over time. It's been very inspiring.

  • 11:52:31

    REHMAll right. And let's go to Houston, Texas. Camille, you're on the air.

  • 11:52:40

    CAMILLEHello. Thank you for taking my call.

  • 11:52:41

    REHMSurely.

  • 11:52:43

    CAMILLEI just want to tell Dr. Farmer what an honor it is to hear him today. I'm a physician in Houston and I've volunteered in Haiti a few times. And my husband has as well. And we're just so lucky to have him as an inspiration and reminder of the important things in life. So thank you so much for all your hard work.

  • 11:53:03

    FARMERWow, thank you, Camille and thank you to your husband, as well, for, you know, engaging in our profession in this work.

  • 11:53:10

    REHMYou're listening to the "The Diane Rehm Show." That reminds me to ask you, since you've been involved in this kind of work since age 23, what about your own personal life? Have you been able to have a personal life aside from your work?

  • 11:53:39

    FARMERWell, first of all, there's no prescription, I would say, for people involved in this work. In other words, there's all sorts of ways to be involved. I just had an email this morning, actually from Texas, from someone who had served with the U.S. military in Iraq who's now planning to go into medicine and was asking the same question. And I don't think there's any one template in being a teacher and trainer of already now 20 years, you know, a couple generations. That's one of the first things you need to explain, is that there's a lot of different ways of getting involved in this work. And sometimes you're lucky enough to have other people in your family, your spouse, your children, involved in this work -- your siblings. And other people don't have that good fortune, you know.

  • 11:54:35

    FARMERAnd I'm lucky enough that my family is very committed to this same work or involved in it. And others, as I said, find that they can do this for this being the direct service delivery, for example, in a place like Haiti or Rwanda or difficult settings in the United States. They don't want to do that full time or they don't want to do that for 30 years or 20 years. That doesn't mean that all of us can't contribute very significantly. And so that's really the important lesson, I think, is that we can't conclude that there's just one way of doing this. It's not the same, for example, if you're a physician who's a young woman who has small children. It may be different because you're retired. It may be different because you're still a trainee. All along the way there has to be room for more than just the work itself.

  • 11:55:31

    REHMAnd for you, has there been the opportunity to create a family, to have and enjoy a personal life?

  • 11:55:41

    FARMERSure, of course. And also, you know, the aspiration, at least I hope--I'd love it if my children were involved in this work, but that is not for me to say. It's for them to decide. And, you know, there's certainly a lot of time required to do this sort of work. I'm hoping, of course, in the future, that it won't be so difficult to say healthcare for poor and vulnerable people has to be central to our society's activities. I'm hoping, reflecting back on your last show, earlier today, that it won't be so hard to train and stipend community health workers, for example, for chronic care. It's been a real struggle, but there's so much progress that's being made on some fronts.

  • 11:56:32

    FARMERFor example, we have tools that were quite unimaginable when I started medical school 30 years ago. And I'm hoping it'll be easier for the next generation to be involved in the manner they see fit.

  • 11:56:45

    REHMPaul Farmer, he's cofounder of Partners in Health, he's chair of the Department of Global Health and Social Medicine at Harvard University Medical School and author of "To Repair The World: Paul Farmer Speaks to the Next Generation." And former President Bill Clinton wrote the foreword to the book. Dr. Farmer, thank you so much for joining us today. Good luck in your work.

  • 11:57:24

    FARMERThank you, Diane. It was a pleasure to be on your show.

  • 11:57:26

    REHMThank you. And thanks for listening. I'm Diane Rehm.

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