July 18, 2012 — Paul Farmer has a clear message on the best way to improve health in resource-poor countries: Build up health care systems, train health care workers, and keep the focus at the community level.
“It’s not rocket science,” the founding director of Partners in Health (PIH) told a standing-room-only crowd in Harvard School of Public Health’s (HSPH) Snyder Auditorium on July 10, 2012. “But it takes a long time to do. It takes a lot more than just writing a policy paper or brief. It actually involves implementation and delivery.”
Farmer is Kolokotrones University Professor at Harvard, chair of the Department of Global Health and Social Medicine at Harvard Medical School, chief of the Division of Global Health Equity at Brigham and Women’s Hospital, and UN Deputy Special Envoy for Haiti under UN Special Envoy for Haiti Bill Clinton. He spoke about “Global Health Equity and the Challenges of Unequal Modernity” in the first installment of HSPH’s Hot Topics summer lecture series.
Farmer talked about his longstanding work in Haiti, which led to the creation of PIH, a 25-year-old nonprofit focused on improving health around the world and addressing socioeconomic factors that exacerbate disease. He also spoke about PIH’s work in other countries, from Russia to Rwanda, and what he’s learned over the years about the best ways to help poor people get access to the health care they often desperately need.
Moving beyond “GOBI”
At age 23, as a first-year medical student at Harvard, Farmer already knew he wanted to focus on public health. He’d just finished a year working with the people of Haiti’s Central Plateau, an area with no access to adequate health care. He took a class on health assessment at HSPH, in which he learned about going from village to village, house to house, to assess people’s health needs. He also learned in the class that if you were working in a poor country, you were supposed to do something called “GOBI.”
“I knew Gobi was a desert somewhere,” Farmer said, “but I wasn’t sure what it meant and I didn’t really have the courage to say, ‘Excuse me, what’s GOBI?’ ”
He learned that it was an acronym that stood for growth monitoring, oral rehydration, breastfeeding, and immunization—things considered, at that time, to be the “essentials” in global health. Then, halfway through the course, he had an epiphany: “Why would you go from house to house and ask people what it is they want if you don’t have any intention of incorporating their wishes into your health plan?,” he said. “If you sit down in a village in Haiti, what do you think they would say if you ask, ‘What do you want in health care?’ The first thing I heard all the time was ‘hospital.’ They also wanted jobs. And they wanted doctors and nurses. No one said anything about GOBI.”
A focus on hospitals, health workers, and primary care
In the years that followed, Farmer focused his efforts not on what “experts” thought poor people needed, but on what they actually asked for. In Haiti, for example, PIH used donated funds to provide drugs to fight diseases like AIDS and tuberculosis, build a multi-service health complex in Cange, and support training programs for health workers. More recently, PIH worked with the Haitian government and private partners to build the 320-bed Mirebalais National Teaching Hospital, slated to open this year. In Rwanda, PIH helped reopen an abandoned hospital and build a new one, supports local health clinics, and focuses on HIV/AIDS prevention and care. PIH now works in a dozen countries around the globe, including Peru, Guatemala, Burundi, and Kazakhstan.
Farmer also spoke about the importance of creating “horizontal” health care programs—those that provide primary, comprehensive care—as opposed to “vertical” programs that focus on just one area, such as family planning, tuberculosis, or AIDS. “The quality of care tends to be good in a vertical program,” Farmer said. “But then someone comes in with a broken arm, and you say, ‘Oh, I’m sorry, we’re the national TB program, you have to go down the street to the national humerus fracture program.’ ” Such programs make health care access too difficult for people, Farmer said.
He also lamented the fact that much of the money spent on global health care winds up in the pockets of consultants. “Someone in here needs to do a book about the overheads for consulting work in global health and find out how big that chunk is,” he said. “The last time the minister of health of Rwanda was in this room, she pegged it at about 50%. In other words, 50% never got to Rwanda. It stayed in the United States of America, in the Beltway. If even 10% of that 50% went into a trust fund for a hospital like this”—Farmer pointed to a slide showing Haiti’s Mirebalais Hospital—“as opposed to only into consultancies for non-Haitians, you could run a hospital like this for a decade.”
photo: Aubrey LaMedica