Morning Lecture Recaps

Thurman: Health diplomacy must overcome religious and cultural barriers

Sandra Thurman, president and CEO of the International AIDS Trust, answers questions after her lecture at the Amphitheater Tuesday. Thurman, a former director of the Office of National AIDS Policy, has advocated the fight against AIDS for more than 20 years. Photo by Ellie Haugsby.

Nick Glunt | Staff Writer

Tuesday’s lecturer Sandra Thurman, president and CEO of the International AIDS Trust, quoted Martin Luther King Jr. to convey her views on global health diplomacy: “We must learn to live together as brothers or perish together as fools.”

The International AIDS Trust is a non-governmental organization that focuses resources to aid the worldwide battle against AIDS. The organization must overcome cultural and religious barriers abroad to take preventative action.

Thurman served as the director of the Office of National AIDS Policy under former President Bill Clinton and has been a leading advocate in the struggle against AIDS for two decades. She was the second speaker for Week One’s topic on “Global Health and Development as Foreign Policy.”

The U.S. Global AIDS program started forming in 1997 under the Clinton administration, Thurman said. The main problem at the beginning was that therapies to combat AIDS were very expensive and complicated
in use.

“There was a lot of doubt whether, No. 1, we could afford to treat people in the developing world,” Thurman said, “and No. 2, whether we could actually do it.”

She credited people like Monday’s speaker Paul Farmer, one of the founders of Partners In Health, in proving that treating underdeveloped countries is entirely possible. She said that oftentimes, people in those less fortunate countries are more willing to accept treatment than those in the developed world.

Though the phrase “health diplomacy” has only recently taken hold, Thurman said people like Farmer have been practicing it for decades. It is now an emerging field of practice in today’s world.

“Health diplomacy,” Thurman said, “provides an opportunity to both proactively and systematically provide interdisciplinary training of health and development professionals and diplomats to dramatically improve the delivery of health care services, development assistance and scientific research.”

Global health as diplomacy

Thurman said that in addition to simply lending aid to those countries, such treatment has created peace in situations of war or unrest.

“The fundamental importance and power of the provision of health services has stabilized situations where politics, frankly, has failed miserably,” she said.

Assistance to health and development can act as the initial steps to “building bridges” between nations, quelling human suffering and creating peace, Thurman said. She posed the worldwide eradication of smallpox in the 1960s, when it was believed that between 80 and 100 percent of the global population needed to be immunized, as an example of such diplomatic action.

Thurman mentioned innovations made by Jim Grant, head of UNICEF from 1980 to 1995, as inspiration for the coming years. Grant sparked a “revolution” to increase child immunizations in developing countries to 80 percent, resulting in 100 million immunizations in China in two day’s time in 1993.

Under former President Jimmy Carter, Grant also discovered that the U.S. could negotiate ceasefires in warring nations like Sudan to provide health care
to children.

“Those people in those countries actually care about their children and families just like all the rest of us do,” Thurman said. “They were willing to find a way to lay down their guns and arms for a number of weeks so that teams from all over the world could come in and actually care for their children.”

Thurman said this is an important lesson. Children are, as she calls them, “the Trojan horse of public health.”

By focusing efforts on the children of the world, people are much more willing to comply with health care efforts.

Facing roadblocks

Thurman said religious and cultural barriers can be detrimental to the development of proper health care practices in these countries.

Sexual behavior is perhaps the most prevalent of these barriers, she said. Misusing or disusing condoms, having multiple sex partners and not being circumcised are some specific practices that increase the spread of AIDS.

To encourage preventative measures, speaking with religious leaders is key, Thurman said; however, she fears it will never fly in some places like Kenya, Tanzania and Uganda, where openly gay men have been murdered by conservative religious sects.

Even in America, there are situations where religion has blocked preventative actions against AIDS. Thurman recalled one particular event at which she bought condoms for the Atlanta-based Sisters of Mercy because they couldn’t let condoms show up in the records. They bought her office supplies in exchange.

She said this is an excellent example of diplomacy “finding ways over
and under.”

To solve issues in developing countries, Thurman said undergraduate and graduate degrees are now regularly combining public health with diplomacy, theology, law, business and development. To influence change, professionals need to have the tools to understand the religion and culture in the places they will work.

“The new cadre of students entering health science training institutions today are going to be the leaders of this work tomorrow,” she said. “We need to make sure we’re giving them the knowledge, support and training that they need to be effective.”

Looking to the future

Thurman said it is necessary to utilize clear, deliberate and thoughtful engagement to solve the grip of AIDS and other infectious diseases.

“All of these kinds of activities require leadership, creativity, maybe a little bit of deceit and investment at the highest levels of politics, academia and the private sector,” Thurman said, “to maximize our efforts on the ground and the fight against diseases all around the world.”

Q: Can you talk a little bit about the coordination among all of the players in this realm? When you think about now, when you have major foundations coming into the game, a number of different countries and agencies that have been doing this work for a long time, how do you all pull together, understand what everybody is up to, and be most effective as a coordinated group?

A: I think it would probably be easier to describe ways that we don’t get along than we do get along. But the fact of the matter is that this is a place where, I think, UN structures actually work. It provides a framework for us to share information as nations and individual agencies in a way that no other framework actually gives us the capacity to do. I think we’re doing better. There’s a current initiative inside the State Department, which has been championed by Secretary of State Hillary Clinton, called the Global Health Initiative, that is making an effort to pull together all of the global health programs inside the U.S. government. This includes the Department of Defense, obviously USAID, CDC, the President’s Emergency Plan for AIDS Relief and others. Although it’s a real challenge to do that, Secretary Clinton has hired a very strong-willed woman — who was from the private sector in health care — who is doing a really good job of cracking the whip and carrying a chair. She might need some other weapon before it’s all over, but she’s doing an extraordinary job of beginning to find ways that we can pull together our U.S. government partners. The wonderful thing that has happened with the growth of the Gates Foundation, as others, is that they have a convening power that almost no one else does. They’re seen as objective, for the most part, partners in this work. They’re funders outside government, so they actually do fund a lot of the same programs that these government agencies fund. They’ve played an important role, and I think almost a moral authority, for those agencies and seem to be doing a good job of calling them to task. We still have a lot of work to do, but I think we’re doing better. UN seems to be the best structure for that to happen.

Q: Is there an inverse relationship between private philanthropy, global health care dollars and government responsibility? Are we simply shifting responsibility from the government to the private sector?

A: I think that, and my hope would be, is that we’re not trying to shift responsibility from the government sector to the private sector. Although in these fiscal times, it’s going to be very difficult for us to maintain our current levels of spending in global health and certainly to get increases in certain areas in global health, what I think is happening is that with the commitment of the Gates Foundation — and again, many others — what we’re seeing is increased pressure on government to actually continue to invest and shift some of their investments to global health from other programs. I think that’s very important, because these donors — both in the non-governmental organizations and in the big foundations — have a tremendous amount of political clout. They’re using that to keep pressure on the government to invest in global health and not so much in defense and other activities. I think they’re playing an important part.

Q: I have two questions in the few I’ve seen so far that go to the issue of the anti-vaccine, anti-immunization movement and what effect it is having.

A: It has had a tremendous effect. Part of our challenge in Nigeria, around polio immunization, was related to the myths that have evolved in this country about vaccination: That vaccination was going to make their children sick, or poison them, or all of these kinds of myths that are floating around. It hasn’t had a huge effect yet in global health, but I’m really concerned about the impact that it’s having domestically, where we see dramatically declining rates of immunization in our children. Of course, the good news is that in most school systems, you can’t put your kids in public school — and I would imagine most private schools; our kids went to public school— without having a certificate of immunization. I think there’s a push back against that, but it’s a place where we need a tremendous amount of education. You’ve seen this happen in AIDS. We forget that we have to continue to educate people, over and over again, as new generations marry and have families and children. We need to make sure that we’re continuing to educate people, even if we make the assumption that people have information already. I think it’s, a tad bit, our own failure in that regard. Aside from some of the myths that we saw around polio immunization, I think that we are doing better, but it is an issue.

Q: Let me follow up with this question that goes to religious and cultural barriers that you encounter. How do you solve them without offending or making enemies of the people you’re trying to help?

A: Well, that’s hard, and I’m not sure that we’re always successful in doing that, but I think it’s part of the reason that it’s so critical that we educate our practitioners, either in diplomacy or public health, in the cultures and religions in which they’re working. We’ve seen this in Kenya; we’ve seen it all over Africa: issues relative to sexual behavior, the use of condoms, multiple partners, sexual practices that put people more at risk. Circumcision is a big issue, more tribal than religious in Africa, but there is a big push to circumcise men in some areas because it reduces the rate of infection in those populations by as much as 30 percent. But adult circumcision is no easy matter, so we’ve had to do a lot of work in educating people. I think we’re making some progress. Engaging religious leaders upfront in conversations about these issues is really important. But, there are some places where I think we’re never going to make headway. We’ve seen that, of late, in Uganda, Kenya and Tanzania, where openly gay men have been murdered as sort of a religious act. Both Muslims and Christians in those communities — very conservative Muslims and Christians — have been a part of that violence. I think there are some places we’re going to have to understand that we aren’t going to make great inroads, but those are the fringes on either side. I think we have a good chance — in conversation, dialog and partnership — of finding ways around these issues. One case in point that I experienced early in my career was working with the Sisters of Mercy in Atlanta. We have Sisters of Mercy doing the same thing in other parts of the world, and I won’t name it because I’m sure their bishops will be cranky. I found a way to help the Sisters of Mercy buy condoms when I was Executive Director of AID Atlanta. They obviously couldn’t put that on the books, but they were serving the homeless and the poor. I bought all the condoms, and they purchased all of my “office supplies.” Again, it’s all about the diplomacy: You have to find ways over and under; that’s what diplomacy is. They would come down in their little white van, with their little red cross on the side, and offload all of their pencils. I’m sure that people who were running the Mercy health care must have wondered what in the world they were doing with all of those tablets, pens and erasers. Nonetheless, they were getting their condoms. They still may be doing that to this day — I’ve been gone awhile. Anyway, I think there are ways we can find common ground.

Q: Let me ask these two questions together. Should we be attacking one disease at a time? The questioner said, “I’m hopeful we can provide comprehensive care.” And where do you see the U.S. playing a role in combating chronic disease abroad, infectious diseases and everything?

A: It’s absolutely true. A couple of things: I think that we can, absolutely, look at treating diseases and preventing diseases across the board. We’ve actually now used our platform of the President’s Emergency Plan for AIDS Relief to expand to reproductive health services, to maternal and child’s health, to immunizations, to other service prevention of mother-to-child transmission of AIDS, from mothers to babies. We’ve used the platform we have built to combat AIDS to now expand to provide other health services. We actually did some of that back in old immunization days, too — built some health care capacity on top of that. But this is the biggest effort we’ve ever had. We are now building out those programs to address other diseases, and that’s part of what the global health initiative, inside of the State Department, is trying to actually do. I think that’s important. The other thing is that we really do have to look at chronic disease. At the end of the day, chronic disease is killing more people than other diseases are. Both here and abroad, we need to be building on existing platforms to address diseases like heart disease, diabetes, cervical cancer, which we’re actually now doing in conjunction with some of our AIDS programs. We’re moving in that direction. But until we slow down these killers that we know we can actually stop, or at least reduce dramatically with relatively few dollars, we need to do that. The fact of the matter is that chronic diseases are a lot more complicated and expensive to treat than engaging in prevention, if we know we can actually stop a disease from happening. Dr. Foege used to say, “No one ever comes up to you and thanks you for preventing the disease that they never got.” It’s a difficult challenge.

Q: What role are the drug and medical supply industries playing in your work?

A: Actually, they have played a major role in this work. We’re actually at a point where drug companies have dramatically reduced the cost of drugs to people in this country, and more importantly, to people in the developing world. We had negotiations with drug companies, through the World Trade Organization and others, about a decade ago, to actually allow us to buy drugs for delivery in Africa that were generic, made in other countries, and not off-patent. That was a huge success. You know, they don’t like to budge on those issues. Medical manufacturers of test kits and other devices have dramatically reduced their cost. Many of them are making very large donations of their goods to clinics, both U.S.-funded clinics and non-profit clinics all over Africa. It took them awhile to step up to the plate, in my personal opinion. I apologize to any drug executives who are in the audience. My personal opinion is we can still do more. We’re looking at the bottom line of those companies and they’re still functioning, making great profits in the billions. I think it would be nice if they would share a little bit of that, but they’ve been very good in recent years in stepping up to the plate.

Q: A couple of questions go to economic equalities and the relationship between the work and the benefit of improving peoples’ health when their economic situation remains less than satisfactory.

A: It’s interesting. It’s a challenge. People’s health becomes a chicken-and-egg situation. If people are suffering from chronic disease or infectious diseases, they can’t work, the children can’t go to school, the parents can’t work on the farm, they can’t send the children to school if they have no income, the children end up falling farther behind, girls wind up engaging in transitional sex, being sold or being abused because they don’t have any income. It’s a very vicious cycle. So at some point in time, I think we have to take a dual strategy. We have to look at providing economic development, support as part of a public health strategy, but that’s long-term, because the majority of the people in the world, as we know, are very poor. It’s a dual strategy; it’s not an either-or proposition. We have to do this hand-in-hand. But if people are sick — or if they have AIDS, or if children’s parents have died of AIDS and they’re caring for four siblings of their own when they’re 12 years old — if we can’t do something to at least keep them healthy, we won’t be able to get very far. If we can keep them healthy, we can at least give them hope. We may not be able to stop poverty at that moment, but if we can keep them healthy, we can at least give them hope that there is a better future. That’s what we’re trying to do, but it’s a delicate balance.

Q: A returning Peace Corps volunteer asks, “Have you involved the Peace Corps in your common-goal efforts?”

A: Absolutely. The Peace Corps is a primary partner of the President’s Emergency Plan for AIDS Relief. We’re now actually educating and training the majority of Peace Corps volunteers, who are working in places hardest hit by the epidemic, in HIV and AIDS activities. Almost every Peace Corps volunteer I’ve meet in Africa is engaged in some kind of HIV and AIDS and other health-related activity, whether it’s mother and child health, neo-natal care, taking care of infants or clean water. They are a major, major player and a very important player because these are folks that are actually living on the ground in community, where those wonderful relationships are developed. These are not people who parachute in — in a suit with goggles or a bag or with this and that — and then, 24 hours later, they’re gone. These are people who live, work and become part of the community. So they are really our best advocates and our best educators.

Q: How have Middle Eastern countries, including Israel, responded to the global health care crisis?

A: It’s interesting; it’s a much more difficult place to work. Obviously, there are resources in many of those countries that are being spent internally on global health issues. Around HIV and AIDS, it’s been very difficult to work in most of those countries because talking about sex, talking with women about reproductive health, even maternal and child health, is a particular challenge in many ways.
But we do see some countries that have done enormously well, like Jordan, which has made maternal and child health and reduction of maternal mortality a priority. That country is really focused on women’s health, which is interesting. But of course, Jordan is not necessarily reflective of some of the other countries in the region. That continues to be a challenge, although many of those countries now have state-of-the-art health care delivery systems. Universities all across the U.S. are partnering with those institutions to expand that delivery capacity. We’re hoping that the situation there will be better.

Q: Can we hear an example of partnership work in a particular country? The questioner suggests AIDS in Uganda.

A: AIDS in Uganda has had some interesting partners. A number of them are actually private partners. Nike has been very involved in girls’ education and girls’ health resource delivery in Uganda. The Nike Foundation is entirely focused on girls’ education and empowerment of girls. They’ve been a wonderful partner.
We have other non-profit organizations like World Vision — a faith-based organization, the largest one in the United States, about a billion dollars a year in services provided overseas. They have been extraordinary partners up in the hardest hit regions in Uganda, where all the child soldiers have been such an issue. They’ve been working up there where many other partners have not been willing to go. And of course, CARE is also in Uganda and in Kenya, doing extraordinary work in partnership there. I haven’t worked in Uganda in the last 10 years as much as Kenya. We have a number of really wonderful private partnerships in Kenya — actually in Uganda, too — with Rotary International. They are doing health clinics and HIV testing days in the same format that we used for national immunization days to get people in, get them tested with volunteers from the community, Rotarians in the community, and then get them connected to some kind of treatment. There are a lot of examples out there of really wonderful partnerships and some real creative ones.

Q: Do you see global health initiatives as including the non-served in this country?

A: Absolutely. I always wonder how we talk about global health and we leave “us” out. That’s probably not a great strategy. The fact of the matter is that we have enormous needs in this country. People in the South, for instance, who are still standing in line and on waiting lists to get AIDS drugs when we’re able to provide them for free in other places in the world. We have to really focus on our own health in the context of global health. These days, it’s a lot easier to do both. The diseases that affect us — again, H1N1, other kinds of influenza that are erupting all over the globe, issues of chronic disease like obesity, heart disease and cancers — affect us all in a very similar way. The way that we invest in research is having global impact. The way that we look at providing comprehensive care, engaging communities in care, looking at faith-based organizations to deliver care — a variety of creative options ought to, more and more, include us in the conversation of global health. I’m tired of “them and us.” We talk about working together and then we immediately engage in a conversation that’s polarized, and we do it over and over again. Doing the same thing over and over again and expecting a different result was, I believe, Einstein’s definition of insanity. I think we might be slightly insane. We’ve got to get with the program.

Q: This is a rather lengthy question, but I think that it is well-framed and very appropriate for our theme this week. Can you comment on the potential pitfalls of framing health assistance as a tool of foreign policy, health diplomacy, particularly the shift in funding for HIV, AIDS and other health assistance programming out of HHS, CDC and USAID, to the State Department, over the last decade or more? Does this shift increase the risk of politics trumping scientific knowledge, and evidence from evaluation, of what works in health and developmental assistance programs?

A: That’s a very good question. I do think that we have to be very careful — and again, that’s sort of my caveat around the language of winning hearts and minds — to focus on some sort of servant leadership, as opposed to other kinds of almost colonialist engagement, in the way that we work with other countries and nations. I do think that there is a risk if we do that, that we have to make really sure that other, outside organizations and entities, certainly universities and other non-profits, are really vigilant in watching what happens in our foreign policy. We need the same kind of advocacy around that that we’ve had in advocacy around HIV and AIDS, generally speaking. I can sort of understand, and of course you know there was a lot of pushback when USAID was merged into the State Department, that they were not happy about it and a lot of people in the development world were not happy about it. But I do think that, at some point in time, we have to have some kind of strategy for engagement that’s comprehensive. If we’re going to move away from this work in silos that we’ve done historically, where you have the Department of Defense working over here, and then four miles down the road you’ve got a big HHS program, and DOD has a clinic over here, and HHS or CDC or somebody has a clinic over here, and then USAID has programs over there — it just creates mass chaos. These poor people really do feel like they’re being invaded. If you’re staying in a country where you have 18 U.S. government agencies working in your country and have no clue to how to get them to coordinate and collaborate, it’s a challenge for them, but it’s an even bigger challenge for us. We can’t articulate what our own people are doing very much. It’s one of the beauties of the President’s Emergency Plan for AIDS Relief. What it’s forced us to do — at least around AIDS at the moment and hopefully, in the long-run, our whole global health response — is to actually sit down and coordinate at the table, not only our own efforts, but the efforts of host countries at the same time. We’re taking their plans, merging them with our plans, and coming up with some sort of common plan that lets us understand and map, with some certainty, the kind of investments and priorities that they have with our own investment and priorities so we’re not falling all over each other.

Transcribed by Lauren Hutchinson

Farmer: Key to global health is community-based care

Dr. Paul Farmer, a founding director of Partners In Health, delivers the season-opening Amphitheater lecture Monday morning. Photo by Megan Tan.

Nick Glunt | Staff Writer

podcastThe screen behind Dr. Paul Farmer depicted a Rwandan man with a short gray beard on his chin, his lips curved into a vague smile. He wore blue cloth pants held up with a loose belt that dangled from his fragile hips. He had no shirt, drawing immediate attention to his frail body. His ribs protruded from underneath his skin, his arms nothing but bone covered with a thin layer of skin. In his right hand, he gripped a wooden walking stick.

“I said upon meeting this man, whose name is John, ‘We have all the medications that we need to get you better,’” Farmer said.

The man didn’t entirely believe him, and neither did the Rwandan doctors — Farmer’s colleagues. This man was suffering from both AIDS and tuberculosis; surely there was no way to keep him healthy. But Farmer’s Haitian colleagues believed it. With Farmer, they had seen something like this so many times.

“This is the same fellow afterwards,” he said, revealing a second photo to gasps and applause from the Amphitheater audience Monday.

This photo depicted a much weightier and visibly happier man. A wide smile spread across his face, and a round belly lobbed over the strap of his gray cloth shorts. Only the man’s beard was similar between the two photos.

Farmer, the first lecturer of the season, is a founder of Partners In Health, an international organization focused on providing medical care to less fortunate patients in the world.

His speech, titled “Partnering with the Poor: One Physician’s Perspective on Global Health,” was the first in Week One’s theme “Global Health and Development as Foreign Policy.”

Partners In Health has centers in Haiti, Peru, the United States, Rwanda, Lesotho, Malawi and Russia, with supported projects in Mexico, Guatemala and Burundi.

Most of Farmer’s lecture, though, focused on the problems facing Haiti today. These problems — like the 2010 earthquake and recent outbreak of cholera — can be fixed, Farmer said, by strengthening world health systems. These issues, as well as his personal narrative, are dissected in his book, Haiti After the Earthquake.

Farmer arrived in Haiti within three days of the earthquake, which he calls an “unnatural disaster.” Haiti was not prepared, he said, for such a disaster, and is still facing the aftermath, almost a year and a half later.

“This is an acute-on-chronic disaster,” Farmer said. “Anybody in this room with a chronic ailment — asthma, diabetes, hypertension — knows that, and you don’t have to be a doctor or a nurse to know that, when you have an acute event like pneumonia, if you already have a chronic illness, it’s more complicated.”

The earthquake, he said, is an acute event worsened by Haiti’s chronic problems. The Haitian government released an estimation of 316,000 deaths as a result of the quake. Approximately 1.3 million people were left homeless. What hospitals that were left standing were filled with people suffering from spinal and brain injuries, crush injuries and multiple fracture wounds. Others faced mental trauma from the events.

In the U.S., there are many “nerve centers” in New York City, San Francisco, Chicago and others. In Haiti, Farmer said, there’s only one — in Port-au-Prince — and it, too, was struck by the quake. Partners HealthCare, a Harvard medical group that employs Farmer, sent more than 100 caregivers into the earthquake zone within one month.

However, many people were displaced because of the earthquake. Haitians left the earthquake zone to find refuge in rural areas, where family lived. The burdens of food and water shortages, which these families were already facing, were exacerbated, Farmer said. Within Port-au-Prince, people moved into open areas like parks and runway strips, living under tarps for shelter.

Furthermore, collapsing buildings killed medical workers as well as the general population. For example, the main nursing school in Port-au-Prince collapsed, crushing those in ongoing classes as well as faculty members.

Partners In Health opened up about 10 clinics in these various areas. And just as the refugees are still there, these clinics are still open today.

“A lot of the emergency response and relief workers have already left Haiti,” Farmer said. “I’m not exactly sure how.”

And then, on Oct. 22, cholera was confirmed in Haiti. There have been more than 331,000 cases, and it’s killed more than 5,000 people as of June 4. Farmer compared the outbreak to a bomb because of how quickly it spread.

In Haiti and the rest of the world, it is imperative to prepare for problems facing global health, he said.

“We’ll never be ready for these problems without thinking about strengthening health systems,” Farmer said. “The same systems that one would build to respond to one health care problem should be, of course, robust enough to respond to others.”

Q: I wonder if you would comment on, not just in the context of the disaster in Haiti and the concentration that has occurred since then, but in the long history you have of working in that country which including some time, frankly, when you were expelled and went back in anyway, so as you think about that and think about the sense of global health in its potential to inform foreign policy, throughout that history, have you had a positive interaction with the State Department or other policymakers and, if so, what is their focus of interest in hearing from you?

A: I’ll just be very personal about this and say that in the first 15 years or so, I actually rarely went to Port-au-Prince and rarely went to Washington. The first time that I gave testimony, some time in the ‘90s, in Congress, at the behest of a radical nun friend of mine, I got convinced by a social justice group to do this; I didn’t really know the scene back then. There weren’t a lot of people interested in what I had to say, which turned out to be right, actually. As the years went by, I learned more and, again, not to embarrass Mark Dybul, but when we started talking about a grand plan around AIDS, it was really to influence the White House, the State Department, to take up these goals. This current administration, in my opinion, is focusing a lot on what some in the State Department, including the secretary, are calling ‘human security,’ and it’s not a novel idea. It’s the idea that if we want to have security, we have to think about things like poverty, inequality; and one of the leading causes of poverty in the world, if not the leading cause of destitution, turns out to be catastrophic illness. So, in my experience, if people I meet take the time to engage the leadership, then you will be rewarded, if you’re patient, diplomatic, courtly, honest, persistent — that has, in my view, yielded a great deal for those of us working in the field on delivering these services I’m calling basic. So, yes, it’s a golden era, in my view, for global health, but also, it’s an era when people are really listening to these old arguments but true about human security as a key to security in general. That’s also one of the reasons why Rwanda is making such strides. They seem to embrace that notion of security as well.

Q: You mentioned working closely with the public-sector institutions. What techniques have you used to minimize the impact of corruption?

A: Well, the public sector does not have the corner market on corruption. Not to be just polemic, if you look at the problem of corruption, and I don’t want to take potshots at the financial sector. Clearly the transnational financial sector was rife with corruption, yet had the bookkeeping seal of approval from the leading houses in the world. So, corruption is a very slippery term, and one thing that I’ve learned over the years is to try to at least struggle to avoid conflating corruption with institutional poverty. So, for example, so that this doesn’t sound arcane, to be transparent requires an infrastructure of transparency — bookkeepers, computers, electricity, water, salaries for the public sector. Rwanda, which has been lifted up, I think, rightly as an example for real struggle for transparency, really pushed this zealously in the public sector. So, in other words, it’s kind of inconvenient when someone you’re working with in the public sector gets thrown into jail. That really was meant to be a joke, so thank you for laughing. But I really think it’s part of our job to struggle, to help deal with lack of transparency, help our partners to become transparent and not be corrupt. So that’s a sort of philosophical answer, but I wanted to say that we had actually tried to do these things inside the public sector — electricity, bookkeepers, the kind of technical assistance that we’ve taken to calling ‘accompaniment’ in our work. Accompaniment means you’re actually going to walk with your partners. That could be a patient or a city government, or a national government, a ministry of health. That’s what Mark (Dybul) and Helene (Gayle) have done with a lot of their careers is accompany at that level. You can also do it at the district or local level, and it requires resources and commitment and patience, and that’s a very difficulty project, but one that’s well worth pursuing over the years.

Q: Does your partnership also include engineers, landscape architects, architects to rebuild, plan and design the community and infrastructure to support your long-term goals?

A: The answer is yes, but I’m smiling because I’m kind of a tree hugger. Looking around and seeing all these trees, I love trees. It’s kind of my hobby, landscaping. Some of my coworkers, who are doctors, thought, Well, Paul’s not going to want to have landscaper volunteers, and I said, ‘Well, that’s not true.’ Actually, in northern Rwanda, we built this beautiful hospital. I wish I put a picture of it in here, but one of the reasons it’s so beautiful is because of engineers, architects and a landscaper — the woman who helped designed The High Line in New York — she lives in Rwanda and she was a volunteer, and I can tell you as proud as I am of things like the hospital I just showed you, it’s much better to have professionals. So, the answer is yes, we have volunteers from management. The day after tomorrow, on my way back to Rwanda; I’m going to be meeting with volunteers in advertising who are trying to help us convey what a really complex message is in a much more concise matter. Let’s just say concision is not my strong suit. So, we have volunteers from every walk of life, not just doctors and nurses.

Q: There are a number of questions that go to your personal experience with all this. This questioner participated in relief efforts in the field hospital set up by Harvard Medical Initiative on the ground of the Love A Child orphanage and continues medical work in poor Haitian neighborhoods. The question is: How do you do the work you do without internalizing the grief you see every day and the suffering?

A: I think doctors do internalize the grief and the suffering, and nurses, looking at my colleague. That is not a bad thing to do. Being cognizant of someone’s pain is obviously what empathy is all about. The question is how to be effective and focus on good outcomes for patients, for families, for areas, for systems, when you’re exposed to a lot of grief. I think one of the best ways to do that, and I’ll say this in an avuncular manner to any young people, or not young people, is with partnership. None of this work is done effectively with small groups. It’s really about bringing lots of people together. I don’t know what we would do in Haiti without our Haitian partners, who I regard as some of the toughest people I know in terms of helping all of us who are ‘transnational bilaterals.’ So, my coworkers who are American or European who are working in very difficult circumstances, all of us need to be spelled, including our Haitian colleagues. We’re really trying to think more about this in the future. Should we have a sabbatical system? Should we have shorter stints of engagement in the field? And the answer to all those questions is almost surely yes. So the main advice I’m giving you is you’re always going to work with a team; remember that it’s all about partnership, and everybody needs to be spelled.

Q: One of the things that is talked about in terms of responses to disasters are unintended consequences. You send in a lot of foodstuffs and you end up destroying a local marketplace; the farmers are driven right out of business. This questioner asks if there is a similar affect on the indigenous medical care — hospitals, clinics, doctors — that are trying to make it with a huge influx.

A: Well, that was the claim of the private sector providers in Haiti. They were being ruined by all of this free care. I think that they Haitian poor would be quick to point out that those people were not providing services for the poor before the earthquake. Very sharp critics, the Haitians. So, the claim was made many times, and very publically, and picked up by the international press, including the American press, was that the unintended consequence of all this free medical assistance and free water was damaging the local economy. I don’t find that a very compelling argument. What I would say is that sector, the private sector, was not providing adequate water, shelter, primary care or primary education before the quake, so we need a third answer. The unintended consequences, however, are after years, decade after decade, and I think we’re starting to learn more about predicting the consequences of engagement. It’s just that we need a big-picture analysis. You’re not going to understand food and security in Haiti by looking in Haiti. You have to look at the transnational economy. You have to look at U.S. agricultural arrangements to understand agriculture in Haiti, and that’s important to do.

Q: Do you think that the model, which Partners in Health has developed for developing under-resourced countries, has any relevance or value for the health care debate in the United States?

A: I do. I do think it does. I think you could even call this a technical part of this and, again, I hope that Helene (Gayle) will talk about this and others who are thinking about lessons learned in global health that could be applied here. One of the main ones, the technical ones, is community-based care for chronic disease. As someone who spends most of his clinical time outside the United States, listening to the debate about medical homes in the United States, they’re really still not talking about homes. It’s almost like we can’t get quite get to the point in the United States where we talk about home-based care, community health workers, really community-based care for chronic disease. That’s going to be absolutely critical to improving quality, and, I believe, lowering relative costs, although there’s a kind of fetishization of dropping cost. If we focus on quality, we’ll end up doing what we did in Haiti, which is to provide community-based care for chronic disease. That’s what our Boston project is all about. The patients who we’re serving there have fallen through the cracks of the most fantastic teaching hospitals you can imagine, and they’re still doing poorly with the people we started with in the Boston area had HIV disease, but we’ve extended that to major mental illness and diabetes, and most of the people we’re caring for in Boston with community-based care, with community health workers, have more than one diagnosis. I know this is adding a little bit onto the answer, but I was in a (neurologic disorder) conference in Uganda, and I was making a plea for community-based care, and I said, ‘We really need to have community health workers to train and involve them.’ I gave an example, unwisely, from Kenya because we had a neurologist visiting us at Harvard, in the ‘90s, and he did a study of the blood levels of seizure medicine somewhere in Nairobi. This isn’t even rural Kenya; it’s the capital city, and zero percent of the patients with seizure disorder who were being followed in a seizure clinic, had the correct blood level. They all had under treatment. Those are the people who actually made it in there. So, I was saying, ‘Look, we need community health workers,’ and a colleague who didn’t say where he was from in Africa, but I guarantee it was a capital city, got up and said, ‘Well, you wouldn’t say this, in the United States, that we should have community health workers.’ I was very happy to say, ‘That’s not true at all.’ I say this everywhere I go. I’m not changing the message from Boston to Kampala. It’s because I believe this is the best way to respond to these chronic illnesses: community-based care.

Q: This is from a group of students from the University of Pittsburgh, Student Leaders in International Medicine. We’ve met with Dr. Joseph in Malawi. Can you comment on your involvement in Malawi and its success? Also, do you need another personal assistant?

A: That’s very nice of you. Thank you guys. As long as it can be indentured labor, but they’re against that at Chautauqua. Dr. Joseph, who’s from Upstate New York, was a student of mine. He’s been working for Partners in Health for 15 years in Peru, in Haiti, in Boston, and then he went to direct PIH’s program in rural Malawi. It’s very much like all of our efforts in rural and urban areas, too. We’re doing three things at once: rebuilding infrastructure (in this case, there was no hospital in this district, as you may know), training local people to do this work and also putting resources into the system. So, that’s what happening in Malawi. The impact of those interventions, which have been fairly modest, again in partnership with the Clinton Foundation and the Ministry of Health, have been just enormous in terms of maternal mortality. In other words, the health system strengthening approach has led to massive reduction in infant mortality, maternal mortality, juvenile mortality and great outcomes among the patients we’ve been taking care of. So, to me, Malawi is just another conformation that many parts of this model are perhaps distinct from place to place, but most of them are actually general and applicable from the urban United States to the mountains of Lesotho. That’s what I believe the Malawi experience teaches us, too. Thank you for asking.

Q: In my view, you have all the characteristics of a modern-day visionary. Do you credit your commitment to the world of public health to a particular person in your life? Who inspired your great work — a parent, a grandparent, a religious leader? If none of the above, what about you drives your incredible mission to help others answering the question: How to make things better?

A: I’ve got to say that I think that is very common in public health, and I’m not trying to embarrass my friends who are here, including Helene (Gayle), who’s the reason I’m here today, but the people I know in public health really share that vision. I don’t know who asked the question, but I don’t think it’s rare in public health or public education. I believe it’s very common. Another thing that struck me, and it’s not just the Pittsburgh students who are making me say this, is that it’s also very common on the university campuses in the United States. I don’t have much experience in Europe or Asia; my experience is United States, Latin America and Africa. It’s just not rare, so people should not exceptionalize and, above all, I hope they won’t pathologize commitment to social justice. It’s common, and we need it. I will say that my oldest daughter, who read me, out loud, an essay, ‘Who’s her hero?’ and she said, ‘Martin Luther King.’ There are people in the world who we all know who are embodiments of real commitment to struggle to make things better. Of course, there are the Dorothy Days and the Martin Luther Kings, figures from Upstate New York in the 19th century. I gave the graduation speech at Wesleyan, and I said, ‘This is the coolest institution ever founded by white people in the 19th century.’ That was my opening line. But what I really want to say is there are these heroes, but there are everyday heroes — people who are struggling, women in rural Haiti who are struggling to keep their families safe and their kids in school — and I think it’s better for all of us to understand to not exceptionalize commitment, not just to one’s own family but to making things better. I think it’s a very under-recognized value in our species, and it’s much more common than avarice that we hear so much about, including in 2008 with the financial whatever it was, I’ve met a lot of people in that sector who are big supporters of Partners in Health who are upstanding, good people, too, so I don’t want to say that this commitment to make things better is just in public health, although I think it’s very common in public health. I think Helene (Gayle) and Mark (Dybul) would agree with me.

Transcribed by Patrick Hosken

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