Partners in Health

05.10.13

Paul Farmer: The Big Idea on Health Care

The charismatic doctor and social activist, known for his work in Haiti and co-founding the organization Partners in Health, talks about why the American health-care system is not working, and what advice he has for the new crop of college graduates entering the real world. His commencement speeches have been collected in the new book To Repair the World.

What is your big idea to impart on college graduates?

The big idea that I underline for medical students would be different from, but related to, a big idea I would share with college graduates. Let me give it a try. It may not sound like a big-enough idea.

I look at American medicine, and I look at how much money we are investing in health care—more than any other country in the world. And you see some of the wonderful possibilities that come out of it, when you have good research linked to care delivery. I would even mention the Boston Marathon bombing. There’s a reason that no one who was injured and made it to a hospital died—because we have really good hospitals in that city, as much as any city. I work in one of them, the Brigham. It is a pleasure to be in a hospital where there are thousands of competent, compassionate people working together for people who are sick or injured.

At the same time, the American health-care system does not perform as well, when you start looking at community-based care, for example, of chronic disease. When you start looking at people with multiple illnesses at once, which you see very often among the poor, and among the elderly as well, then our system doesn’t work well at all. So the big idea that I would give to graduates of medical schools and nursing schools is that we can only have real impact, and the best impact, when we work in teams. And those teams have to reach from hospitals and clinics, to communities. And that's where I hope American medicine is going. The big idea, in that case, is we need to learn how to work with community health workers in the United States, just like we do in Haiti, Rwanda, Malawi, Lesotho. 

Are you saying we can learn from the way that we work in Haiti, to help our own system? It's almost saying that our system needs as much, if not more, work, than what we think are these third-world, developing countries? Is that fair to say?

That's fair to say. Obviously, we have things to teach our colleagues elsewhere. But we have a lot to learn, too. And some of these lessons are going to come from places like Rwanda. People talk about reverse innovation, or some people use the term frugal innovation—although I’m less convinced that that’s a good solution to these failures of imagination—but reverse innovation is definitely something of interest to all of us working in Partners in Health. Building health systems in one place, learning lessons from them, applying those lessons elsewhere, going back to the first place and improving again—there’s a lot of systems improvement needed in the United States, and some of it could come from health systems elsewhere. 

Another example from this past week: this new medical center that we built [in Haiti], through partnership, is now the largest solar-powered hospital in the developing world. It’s not that the technology was created in Haiti. It’s just that it was deployed in Haiti. And I think there’s things to learn about how we fuel our institutions as well.

The American health-care system does not perform as well when you start looking at community-based care, for example, of chronic disease.

Do you think the Obama administration is moving toward these goals in the right way?

I think that we are moving toward these goals, but too slowly. For example, when my colleagues have started initiatives to promote community-based care, and work with community health workers in places like Boston, it’s just been too difficult to keep making the argument that this is the right thing to do. In other words, we have to work against this undertow of censorious opinion that isn’t fair, that isn’t accurate. We shouldn’t have to keep on showing that [community-based care] improves clinical outcomes—which is the most important thing. It improves the value for the amount invested for the patients. It also decreases inappropriate use of, say, emergency rooms. And the studies that we’re doing and others are doing show it decreases cost. So the direction is right, but it ought to speed up. 

farmer-repair-world-cover
“To Repair the World: Paul Farmer Speaks to the Next Generation,” by Paul Farmer. 294 pp. University of California Press. $27. ()

We can’t show, for example, that our current system of hospital- or clinic-based care can deliver reliably the services that are needed on a daily basis to people living with one or two or three chronic diseases. If you look at people who seek a lot of care in American cities for multiple illnesses, it’s usually people with a number of overwhelming illnesses and a lot of social problems, like housing instability, unemployment, lack of insurance, lack of housing, or just bad housing. If there’s any way we can move our medical system to be aware of the importance of addressing these problems for patients, and moving care out to them but also expanding the notion of what it is that we do—again, working with other partners—I think we’d see a lot of return on investment in health care in the United States, or a lot more than what we’ve seen to date.

One of the best ways to promote child survival is to invest in girls’ education and gender equity—because that gives a higher return than a lot of the medical interventions that we might do.

In your book, I counted that you give, on average, two or three commencement speeches a year, and I’m sure these are only a portion of the speeches you give. How do you not repeat yourself?

I find it very difficult to do. For example, this year I’m giving three, none of them to a medical school. I really want them each to be different. So finding a narrative that could be compelling to young people, and also their families, in three different institutions, is hard to do. At least it’s hard for me. 

But the reason I’m interested in doing it is because, you know, I’m middle-aged. I’ve been doing this work for 30 years. I see the progress that’s been made, at least in global health in the last 15, 20 years. We need young people to be interested in these problems. I focused a lot on health problems, but basically what I’m talking about are social and economic rights that would allow us to attack extreme poverty. That means the right to health care, the right to a decent job, housing. These are difficult topics. And anybody who thinks that he or she has the right answers is probably pretty immodest and wrong. But getting people interested at that age in these topics is important.

I can go on. I don’t know much about climate change. But I’m pretty sure we better figure out what to do to lessen its impact—at least its health impact—and that’s not going to happen unless you have a lot of young talent interested in these topics. I have a colleague from Harvard who’s since passed away, Paul Epstein, who studied the impact of climate change and vector-borne infectious diseases—for example, a parasitic disease like malaria. You have increasing temperatures higher up in a mountain, for example, where I might work in Africa, and you see epidemic transmissions of malaria that you didn’t see before. Just to give you a concrete example. And that’s to say nothing about rising sea levels, and all the other things I read about in the popular press. It’s difficult to imagine that these kinds of problems are not important for human health and well being. And I’m trying to learn about them too, and become a better global citizen, on areas outside my own arena. 

Everybody should be interested in access to primary and secondary education for everybody. Once you learn, for example, by reading outside of your field, that one of the best ways to promote child survival is to invest in girls’ education and gender equity—because that gives a higher return than a lot of the medical interventions that we might do—it’s not OK to not know those things. It’s not OK to not know some of those basic facts. 

This interview has been edited and condensed.