Global healer: An interview with Paul Farmer

You’ve referred to Americans as "lazy democrats." How does this assessment describe America’s relationship with Haiti?

We’re lazy democrats in that many of us were born in a very affluent society. As a child, I never had to fight to go to school or even to have clean drinking water. Very few U.S. kids in the latter half of the 20th century did. Yet few of us are engaged in protecting our democracy by getting informed on all the issues, from health care to foreign policy, and then voting. The Haitians vote in far greater numbers, in terms of proportions, than we do.

This has had an enormous impact on our relationship with Haiti. I believe most Americans are basically decent people who would not endorse funding paramilitary groups to take over a nation, or block water aid to the thirstiest country in the Western world. Yet they have allowed their government to do these things in Haiti. If our policies toward Haiti do not reflect our national character, we Americans must be lazy democrats: we accept foreign policies that don’t reflect the people’s volition.

You’ve said that "tuberculosis makes its own preferential option for the poor." What do you mean?

Tuberculosis is an air-borne disease, and “anyone can get it,” as people say. But why doesn’t everyone get it? Because those who live in crowded conditions, are malnourished and are around people with TB who don’t have ready access to care—namely, the poor—are those most likely to acquire and then pass on this disease. They are also the only people in the modern world likely to die of TB, since it’s almost 100 percent curable. So why does TB still kill 2 million people each year? Why indeed.

Why is it so difficult to obtain medicine for the countries that need it most? What changes would you like to see in drug availability and pricing?

Availability varies from place to place. Medicines are not that difficult to acquire in Russia, for example. Russia reminds me in some ways of the U.S.: people there are apt to be big consumers of medications, including over-the-counter medicines. The difficulty there was in trying to obtain hard-to-find drugs for drug-resistant TB and then getting them to people in the prison system where the disease is rampant. Haiti was on the other end of the spectrum: the poor didn’t have any modern medicines, or not enough to matter. So Partners in Health (PIH) must think through an entire drug procurement and distribution system when they address public health issues.

The principles of availability are simple: medicines and diagnostics should follow the pathology. In other words, “Let’s move the drugs to where the patients are.” And the chief pricing policy would be, “Make sure the destitute sick have access.” The two statements could be the planks of a serious effort to reform current practices, if there were enough political will.

How do you assess the presidency of Jean-Bertrand Aristide, who was forced to leave office in 2003?

A student in Boston recently asked me if power had gone to Aristide’s head and I replied, “I don’t know. He’d have to have power first.” Aristide was elected twice by the overwhelming majority of Haitians, and his support came largely from the poor, also the majority. But he was overthrown by military and paramilitary bodies in both instances. So how can we assess his presidency? Over the past three years, we’ve learned just how little power he’s had. If a third party (the U.S. government) can block already-approved loans for health, water, education and road projects, how can one even talk about the Haitian government as sovereign and “in power”? Despite his lack of power he nonetheless disbanded the hated and costly military, built more schools than have been built in the past two centuries together, and provided freedom of speech, assembly and media.

You’ve said that "erasing history serves the interests of power." How is this true in Haiti?

That’s where I learned it. The current reporting on recent events has convinced me that this is more true than ever. As a physician in rural Haiti, where I see the disastrous results of forgetting history, I believe that every literate person of good will should at least try to counter the massive amount of propaganda coming from the powerful in Port-au-Prince and Washington. We should at least make it difficult to erase history.

What steps could the U.S. take in implementing an effective long-range policy for Haiti?

We could side with the right of the poor majority to elect the government of their choice. You know—one person, one vote. We could respect the right of the Haitians to follow the economic-development strategies of their choice. We should stop arming the Dominican border so heavily (this is a country with no external or internal enemies), since these arms are almost surely involved in the awful events of the recent past. Above all, we should reject our past policies as failures.

You’ve said that "when others write about people who live on the edge, who challenge their comfortable lives—and it has happened to me—they usually do it in a way that allows a reader a way out." Can you say more about that?

Every example of extreme commitment is usually accompanied with reassurances that such commitment reflects zealotry or some other pathology. I’m always trying to reassure my own students, for example, that they don’t have to go off and live in a slum to make a contribution to global health equity. So I allow them a way out. With those major figures who have made the ultimate sacrifice—from Dorothy Day to the Jesuits in El Salvador to Martin Luther King Jr. or even Nelson Mandela—there are always efforts to brand them as “a bit off.”

What or who led you to Haiti?

I followed the migrant farmworkers in the U.S.

You spend a good portion of your life on airplanes, flying around the world as an advocate for the sick in Peru, Russia and elsewhere. Your family is in France, and you practice medicine in both Boston and Haiti. How do you decide where to be on a given day?

I’d like to make it sound as if I have some careful formula with which I balance the relative merit of any decision. I don’t. And everywhere I go, I’m gone from somewhere else—that’s hard. But I do work with a great team, especially in Boston and Haiti, and some of us have been working together for two decades. That’s comforting. Also, the team is much bigger now. I’ll bet the medical director of PIH, Joia Mukherjee, outtraveled me this past year. If only we could clone her.