New Book, Old Paul Farmer: Discuss
Anyone who can draw six hundred people paying $30.00 a head to a Washington DC book launch at 9.00am on a Monday morning qualifies for guru status. Anyone who insists on staying to sign the books of the hundreds who lined up for a personal dedication, thoroughly deserves that status.
Yet what is Paul Farmer, an infectious disease doctor who along with Haitian colleagues has probably tried to answer more of Haiti’s key development questions than any other blan alive, now selling? Just as importantly, given his Pied Piper status, what are his followers buying?
The short answer is a breathlessly reflective diary of his year post earthquake. Here he is sporting all his multiple hats: global health visionary, Deputy UN Special Envoy to Haiti, founder of Haiti’s leading health care provider and, in what probably means most to him and Haitians, simply Doktor Paul.
Can he bestride all these worlds, respond to the medical emergency, launch a massive drive for reconstruction funds, then change policy and practice to administer them? Can he manage sometimes conflicting responsibilities, find common ground, build bridges between different worlds? Read and decide.
This book is a diagnosis of the urgent need for the transformation of development assistance to Haiti, for the “international community” to pay for the provision of basic social services through the public sector, and a rallying call to fund the Haitian government, rather than outside parties, to do so. Public provision offers a more accountable, more permanent, more Haitian means of delivery than foreign NGOs or private companies, Farmer argues, showing how this conviction has evolved from both personal experience and a real understanding of Haitian history.
It’s the cohesive, consistent thesis that has underpinned all Farmer’s work and writing to date. Having said that, here there are few of the specific curative prescriptions that we know Paul Farmer is so capable of producing. The result is often more questions than answers and some sense of incompleteness. The book, Haiti, After the Earthquake (Public Affairs, New York) is reviewed elsewhere on this website (link) so this article will explore Paul Farmer through what he says “in conversation” on his book tour.
Chelsea Clinton is said to have described Paul Farmer as the “Albert Schweitzer of our time” when recommending him to her father. That Farmer, a Global Health Professor at Harvard and crucially a medical anthropologist (“ask people, listen to your patients before diagnosing or treating”) is one of the leading humanitarians of our time, is beyond doubt.
Since he turned up in Cange, in Haiti’s central plateau, the poorest village in the poorest region, to found, a clinic, which became a model hospital, which through community outreach, became in Partners in Health (PIH) and it’s Haitian equivalent Zanmi Lasante (ZL), one of the largest health care providers in Haiti, Paul Farmer has become even more than all that.
As Haiti’s best-known public health advocate abroad, and one of the globe’s leading public health advocates worldwide, Farmer has forged a model for NGOs/CSOs working inside, rather than outside, the under-resourced, public heath care system in Haiti. His medical practice is founded on his medical politics, namely a bedrock belief that the best health care humans are capable of is a basic right for all. As such, he and PIH and ZL have focused ruthlessly on those whose health rights are most denied — Haiti’s poorest, those still “dying of nineteenth century diseases in the 21st century.”
In 2009, after the break down of negotiations to find a way for him to bring this vision to USAID, he accepted the unpaid post of UN Deputy Special Envoy to Haiti under Bill Clinton. While still feeling his way into the UN, now a “diplomat” who many feared would have to compromise his instincts and message to speak truth to power and retain any influence, the earthquake of January 10, 2010 devastated Port-au-Prince and beyond.
The format of the Washington DC event — billed as Paul Farmer “discussing his new book” — helped no one in disentangling the parameters of the dilemmas facing Paul Farmer, which are, at varyingly lower levels, those facing all those who work in or on Haiti. The first 40-minutes was Paul Farmer discussing Haiti, cholera, medical NGOs, “doctor to doctor” with CBS News’ on-screen medical expert, Dr. John Lapook.
Lapook has visited Haiti, has read the book and knows Paul Farmer — indeed, knows him too well. Much of the time this resembled a private bar-room chat, which left the audience feeling like intruders. All this left time for just three questions from an audience of more than 600 before the real business, signing books got underway. Well, this is America.
Paul Farmer did find a chance in response to one question to characterize the book as “an inside critique of the NGOs and the UN, not a savage critique.” With the use of the word “positive” in his next phrase, he seemed to mean a positive critique, a positive appraisal. Well, yes and no (see our review of the book).
The book is far too much of a chronological diary and evidently far too understandably hurried to have time and space for detailed analysis, although always lingering is the suspicion that any such thing would be too scathing to carry the name of a man with a UN title. And to be fair, it maybe too soon for such a definitive view anyway, even from inside.
There were, to use the medical metaphors that pervaded the conversation, a lot of diagnoses but few detailed prescriptions. There was mention of the “800lb gorilla in the room, the NGOs” – the means by which humanitarian and development aid to Haiti has been privatized and the government bypassed. Then, as if to make the point, there was no real discussion of the different classes of NGOs, no mention of the fact that through their funding many are now effectively subsidiaries of western governments in Haiti, making the term NGO a total contradiction in terms.
“We need to ask questions. What are we doing wrong?” Farmer asked, answering his own question, apparently lumping together the worst of the NGOs with the best, like his own. “We have allowed the unintended degradation of the public sector. The earthquake is our chance to improve our own practice and our conversation with other NGOs.”
There was no allowance for the fact that the cause and effect might not be “unintended” – indeed, that western aid and development policy in Haiti may have very intentionally weakened the Haitian public sector and the government on which it was based. There was no mention of what the agenda of any such conversation with NGOs might be. Asides about the Red Cross being “a good brand” (but by implication little else?), Medecins San Frontieres, being “Doctors Who Sometimes Need Borders,” simply hinted at the necessity of the debate.
History was fine; its relationship to the present and thus potential solutions seemed more of a problem. “We sided with the slave owners,” said Paul Farmer, in his brief obligatory run through Haitian history. But aren’t we still doing so, Paul? If not, why are we paying for “development” that consists of erecting assembly plant shells, whose owners and operators refuse to pay even the minimum wage – a sum that the very same factory owners openly admit cannot support an individual let alone whole families?
Hasn’t much of the relief and reconstruction aid lined the pockets of the elite – the tiny elite who have shown themselves so impervious to even the most minimal demands of the poorest – as the foreign relief agencies paid to use the trucks, the water supply, the distribution system they monopolize? Won’t the reconstruction aid in Haiti now line the same pockets, the little that does not go straight back hence it came to western contractors, consultants, controllers in all the classic hallmarks of disaster capitalism? Discuss, Paul, as you might invite your Harvard students to do.
Isn’t the effective alliance of western governments and the Haitian elite, the latter’s effective refusal to pay any form of income or property tax and western taxpayers effective endorsement of that though our governments refusal to impose on the them the sort of economic “restructuring” that has so devastated the poor in Haiti, the real reason the Haitian Ministry of Health has a budget of less than $45 million a year? That’s about one third of what the wealthiest health NGOs have spent in Haiti in the past year as you pointed out.
Who says the 30-year war on the public sector, led by multilateral financial institutions and their donors, whose policies leave you and other NGOs to pick up the casualties, is “unintended”? Isn’t the state Haitians live in, the state their country’s tiny elite have always insisted on? Is it not built to the specifications of the multilateral institutions (IMF/ World Bank, IDB) – a neo-liberal model, with all public utilities sold off or under offer, with public provision almost non-existent, a model now increasingly under “re-construction” somewhere near you, reader, in the developed world?
John Lapook deserves some credit for getting Paul Farmer to expound on the individual versus the institutional, the personal versus the policy as another core of his philosophy. Few have been better as a doctor or public health advocate at understanding that in treating the individual today you can minimize the prospect of a sound, public access health policy for the future unless you chose the means and method of delivery with real care.
Few doctors anywhere have sought to better understand the context of the poor patient, what has made them sick or in poor health and what needs to be done to prevent it. Prescriptions at Cange, PIH/ZL’s prototype clinic and hospital, are as likely to be a long-term social preventions — a new roof, a job, foodstuffs — as they are short-term cures such as drugs or therapy.
It was an issue Paul Farmer returned to obliquely when fed a leading question by a journalist on behalf of faith group NGOs, baffled at their failure to change Haiti long-term despite millions in aid and personnel over decades. “Your mission is difficult but it can be complementary to public health, education, water provision,” he replied, without specifics, going on to imply that all NGOs need to improve. “Look at the cholera epidemic. It spread like wildfire through an area we’d been working in for 25 years so we didn’t get everything right.”
It was a bizarre critique of PIH/ZL for its response to a pathogen which we now know — thanks largely to Paul Farmer’s own pressure on the UN to come clean — was introduced to the river system in Mirebalais by UN Peacekeepers. Not a deliberate act, admittedly, but a product of criminal negligence all along the UN chain of command from New York to Haiti.
The comparison to Bhopal that one commentator has made (see our Blog) hardly seems exaggerated. As HSG has pointed out before, someone in the UN assigned troops from a country (Nepal) where cholera is endemic, where there had been a recent virulent outbreak of the disease, without any testing of the troops assigned, or any thought for the possible consequences for Haiti, where even rudimentary sanitation had broken down post earthquake.
Given his phenomenal commitment to Haiti, his success in forging new models, opening new debates, no one doubts that Paul Farmer’s decision to take the UN job was motivated by his 30-year old burning desire to change things – on a much bigger scale. But transforming the UN and western aid paradigms maybe a task beyond even Paul Farmer – although incremental change, while insufficient, might in itself, be worthwhile. The impossible you’ve done for the past 25 years Paul Farmer; miracles, even by you, take a little longer.