Author Talk With Paul Farmer
In his new book -- Partner to the Poor: A Paul Farmer Reader -- Paul Farmer, acclaimed 'saint,' chronicles his true-life, world-saving adventures.
Dr. Farmer talks with Diana Silver, Ph.D., about his work and the new book.
DS: Let’s begin with Haiti. How is the relief effort going?
PF: A lot of energy and resources went into immediate rescue and relief efforts -- with predictable results: not many people could be rescued. This is not atypical of a disaster of this magnitude.
The reconstruction efforts are slower. There are fewer resources. It is taking a while to get things going. Though there has been enormous effort to coordinate a better response, we can’t give ourselves good marks yet on reconstruction. For one thing, the number of people in camps with displaced homes continues to grow, not to shrink. That’s the biggest problem: shelter and basic services for people who have lost their homes, or are afraid to return to them. We haven’t been able to help much in this regard.
DS: Is there -- anywhere in this difficult situation -- cause for hope?
PF: Reconstruction is slower than what I/we hoped. This was a catastrophe on a nearly unprecedented scale. Some think as many as 20% of all federal employees were killed; all federal buildings destroyed. So how quickly can we expect reconstruction? But there are glimmers of hope – including the creation of the Interim Committee for the Reconstruction of Haiti, which had its first meeting and is designed to green-light a broad range of solid projects.
DS: Let’s talk about your new book, which is a gift to professors, because it is so beautifully organized. It’s organized dramatically, rather than chronologically. Can you describe the dramatic, organizing themes and say a bit about why you structured the book in the way that you did?
PF: Some of the early pieces cover the anthropology of epidemic disease and focus on Haiti, where I’ve worked for the last 28 years. It moves more broadly to some of the issues that animated the first years of my work, but focuses more explicitly on basic social and economic rights for people living in poverty. By basic rights, I mean the rights to water, health care, education and shelter. The issue of
sexual violence runs through the book. It’s a very difficult issue for physicians. There’s a focus on social forces that put some people at risk for illness or other bad outcomes. Racism is an example -- as is gender inequality.
DS: Structural violence is a loaded term. I imagine you use it intentionally. Could you speak elaborate?
PF: It is not an original concept. Many have found it to be too loaded. I began using the term to convey the sentiments and the experience of people I worked with in Haiti, in Peru, later in Africa. These people experienced every day life as violent and used loaded terms to describe their experience.
Let me give you an example. A woman in rural Haiti has many children and spends every waking hour in a struggle for food, for wood to cook with, and for water; she experiences this as a kind of violence done to her. I think it’s better for those in my position to echo her view, not just her anger, but also the sense of injustice with which she regards her experience I’m not wedded to the concept, but it is useful.
DS: In the section on structural violence in the book, you introduce the idea that health is a human right. And, you critique human rights groups that adopt political neutral positions or focus on civil rights, rather than human rights. Is this a fair description?
PF: It is an insider-loyalist critique. A number of prominent rights groups advocate for political and civil rights. These are important struggles. But there are other rights: the right to health care, the right to clean water, the right to education. These are the rights I consistently heard about in places like Haiti. And very often these rights are not much discussed in mainstream health organizations. So, yes, mine is an insider loyalist critique of an overly narrow focus on civil- and political rights.
DS: You have been critical of neoliberalism and some of its solutions to some of these problems. Can you say a bit about this?
PF: There are broad economic policies that favor social safety nets and others that really don’t. If you look back over discussions on various economic disasters in the country -- like the Great Depression -- this was a very vibrant topic of discussion. FDR and his cabinet members were very explicit about the need to think hard about the ill fed, ill housed and unemployed.
This is something Americans ought to be proud of; it’s part of our history too, just as is the more unfettered growth period that can sometimes collapse as we’ve seen with the recent economic set backs. It is important to say that we need to fight more to make sure that everyone has a right to basic health care. We are not going to see this happen under a lot of these more neoliberal economic policies. Another way of putting this: we need to focus on social protection as it benefits our physical and emotional well being, and also strengthens the economic well being of the public.
DS: Some advocate for neo-liberalism on pragmatic grounds. But your critique of neo-liberalism is also made on pragmatic grounds, yes?
PF: If you find 10,000 NGOs, as you do in Haiti, then you know that they are filling a space left by others. The others, in this case, are the public sector, the state itself. I work at an NGO, as a volunteer for Partners of Health. And I work for a private University. (I’m a professor at Harvard, that’s what I do for a living.) So, this is not an attack on the private sector of NGO -- after all, I represent an NGO. But, as NGO’s and non-State actors, we must believe in some basic social safety net to strengthen the public sector’s ability to provide basic services. This is a perfectly fine primary goal for an organization like Partners In Health.
Some people think of Rwanda as a place in which a sort-of neo-liberal economic policy is in place. But, if you look at the Rwanda budget, it is pretty shrunken in health care and education. Yes, there is strong encouragement from the private sector, including direct foreign investment. We need this in Haiti. The question is, do we provide this at the expense of any basic right of the population? The answer is: No. This is not in the interests of pragmatists.
Before the earthquake there was very high unemployment in Haiti, and relentless migration to the cities resulted. There was little investment in public work, safety or education. And so there was a perfect, terrible storm, when something as awful as the January 12th quake hit. Haiti has been terribly vulnerable to natural disasters for many decades, because it has been deforested because people need charcoal. And there is no charcoal, because there has been no significant investment in alternative energy sources. Haiti is not alone in that regard. But, as the recent complex chain of events shows us, you can be absolutely pragmatic and still say, ‘hey, we can put in place some basic systems to protect people from the worst.’
Having a safety net for health care is the ultimate in pragmatism. It is not ideological to say that people need a basic safety net. Same for education. It has been shown again and again that a girl’s education is the best way to promote child survival. What could be more pragmatic than equitable education?
DS: Some of your work has challenged epidemiologists, and the public health community, to look at the impact of economic and political policies on health, and focus less narrowly on individual risks for disease. You've also challenged anthropologists to go beyond cultural factors in explaining behaviors that put people at risk, and to investigate the political and economic context. In these ways, you've been pushing both these disciplines to stretch beyond where they have focused much of their attention over the last fifty years. Was this your intent? And do you think you've had an impact on the disciplines as a whole?
PF: That was my intent. It is difficult to measure impact. For the public health community or epidemiologists, there is always some kind of blinder on any methodology or any kind of disciplinary approach. For anthropologists and public health specialists to be blinded in this way is particularly offensive because it is our job to re-socialize our understandings of phenomena.
Again, going back to Haiti, there is an earth quake at 4.33 on January 12th. It is a natural disaster and also a social disaster. It is the job of some disciplines to work hard to make all of this clear. Why? Because understanding claims of causality, how one thing causes the other, is important to any convention. Going back to medical language, to get both the prognosis and the prescription right, you need an accurate diagnosis. This emerges from a comprehensive examination of the history of the illness -- and all the data that we have is laboratory data and modern biomedicine. The underpinning of that critique of my colleagues in public health and anthropology is that we are not going to get the diagnosis correct if we don’t have an historically deep, geographically broad, view. By geographically broad, I mean that if you are looking at epidemic disease you can’t focus your attention on one administrative unit. Usually in the 20th century nation state, epidemics don’t remain local. There is a lot in the book about epidemics. They never stay local. They always get out of prisons and hospitals, and out of one state and into another.
Parochialism about place, just like parochialism about time, is detrimental if we want a full understanding of big social medical questions presented in Haiti and elsewhere around the world.
Paul Farmer is Professor of Social Medicine and the Chair of the Global Health and Social Medicine at Harvard Medical School.
Diana Silver is an assistant professor of public health at New York University's Steinhardt School of Culture, Education and Human Development
