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If you like Paul Farmer's story, you might also like:
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Paul Farmer can also be seen and heard in our Podcast Center

Related Links:
Partners in Health
Clinton Foundation
Global Health Equity
Global Health & Social Medicine

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Paul Farmer
 
Paul Farmer
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Paul Farmer Interview

Founder, Partners in Health

July 3, 2009
Cape Town, South Africa

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  Paul Farmer

You were already in Haiti when you were accepted to Harvard Medical School. How did that come about? Did you already know what you wanted to do when you graduated from college?


Paul Farmer: After I finished at Duke, I thought, "Well, am I gonna have a future in research or in international development work? Am I going to work in an American city or work abroad?" And I was trying to figure that out, like a lot of people who are 22, 23 are trying to do. And I say to my students, including undergraduates, "Go off and find out. Don't try to answer that right when you're 22. I didn't." I went from Duke to the University of Pittsburgh and then to Haiti. And then I went back to Brooklyn. So I had, in that year after college, I got to try a lot of things and see where I might be most comfortable casting my lot as a physician. As I said, I knew I wanted to be a physician, and yeah, I applied to Harvard Medical School and one other medical school, because I was interested in medical anthropology, which is a very arcane little field. It's a narrow strip of scholarly interest in medicine and public health. So I really wanted to go to Harvard, because there were people there I wanted to work with, and I got that letter when I was in Haiti, in the middle of Central Plateau, which is where I still am working to this day.


Were your plans to stay in Haiti indefinitely after college? You didn't know if you'd be accepted to medical school.

Paul Farmer: No, it wasn't open-ended.


I thought it'd be great to learn how to speak Haitian Creole, and it would be very handy to be -- if you're a doctor in the United States on the eastern seaboard -- to get to know Spanish, to get to know Haitian. It wasn't my intention to spend a quarter of a century there. I'm headed back there from here, so it's gonna be more than a quarter of a century. I think it was the right thing not to have a set plan, and I say this to students all the time. Why should you know what you're gonna do when you're 22 or 23 years old? You've gotta allow yourself to be open to new experiences and to keep on learning all the way.


When you arrived in rural Haiti, you found people in a desperate state. Did you find they were resigned to the situation?

Paul Farmer: I wouldn't have put it that way, although other people did. Are Haitians resigned or are they accurate observers of their possibilities? I think back to that particular point in time, say 1983-84. You go into a place, and everything is always dynamic and changing. That doesn't mean you can see it. We're doing this interview in South Africa. I don't know what it felt like to be in South Africa in the '80s, and there are people right here in this room who do.


Going into Haiti at that time, it wasn't clear to me how much things were changing and about to change. So I think people going to Haiti -- Americans or people from Europe -- and they would say the poor are resigned to their fates. I might have said that when I was 24, but I learned, a lot later on, that they weren't resigned to their fates, that there was a power to organize and push for real democratic engagement. It was very inspiring to me. So if I said that, in 1984 when I was 24 years old, that they were resigned, that would have, I think, been an error. I may have said it, but that would have been wrong. Again, you learn things. You keep staying engaged. I wouldn't have thought, for example, that the country of Rwanda could make so much progress in the decade following the genocide in 1994, and yet they have. You know, it's stable, orderly, growing, the economy is prospering. There's a commitment to social services like health and education. I don't think that anyone there in 1995, for example, would have predicted that. So I think it's wise to be humble about what's happening in the dynamic of a place. But I may have said that when I was 24. I hope not, but again I have to look back.


Initially you went to a hospital in Haiti, in between medical school. Can you tell us about the experience there, and why the system either worked or didn't work?

Paul Farmer: Yeah. I went to a lot of healthcare infrastructure in that first year.


I went to clinics, I went to mobile clinics, I went to rally posts, I went to hospitals. I went to well-known hospitals, less well-known hospitals. It was an eye-opener. It was just very disturbing. You know, the quality, and some of them are well funded, some of them are underfunded, some of them were well managed. But I understood how much the odds are stacked against poor people in that year. Again, looking back, following the lines of your interview, in university, in college, you can read about all these things, and I think it's really important to do that. But when you can draw on a lot of reading and studying and hard work about a place, say Haiti for example, and then you head off to that place and actually experience it, then you have a whole different level of learning and experience. And that's what happened to me is, I'd read about it, and I'd try to do due diligence and be assiduous in reading. But then to see it in all these different settings. As I said, clinic, rally post, hospital, it was very mediocre for poor people at best.


So that was the general experience. Wow, the quality of services -- even those set up by people of goodwill, some of them I still work with today -- they still were lousy medical services. It's hard to say that. It's not fun. Maybe this is some advice, too, for people who might look at a video like this.


It's very easy to criticize projects like this. It's very easy to go in, as a privileged person from, say, an American university, and go in and say, "Wow, this is really poor quality care," or very poor quality services. That may be true, and it's easy to say, but it's not always the best way to engage. So what I tried to do is to stay engaged, in spite of the fact that the quality of services was terrible. You know? So that diagnosis is easy. Then what is the prescription? What do you do to really engage to improve things? You know, one of the things that I can look back at with some pride and say is, "Well, at least we stuck with it." So 25 years later, we're still trying to improve and expand. We still have a long way to go, but that's the trick is persistence, staying engaged. You know, people say to me, "What's the secret?" I would say that's the real secret, is -- it's not always a big idea or some innovation. I'll make this point tonight in my remarks, because sometimes what's innovative and what's entrepreneurial is just staying engaged with something that's difficult. You know, just sticking with a tough problem. There are people in this country, for example, who are, say, providing medical services in townships. You know, if they're looking for some magic recipe to radically improve health outcomes, they're not gonna find them. It's really persistent engagement, and fighting for basic services like electricity and water and housing and primary healthcare, and that's what they call in medicine -- they call that scut work. That's just drudgery. But the real innovation sometimes is just sticking with it.

[ Key to Success ] Perseverance


After your first year in Haiti, what did you believe was needed most?


Paul Farmer: If you start in a squatter settlement, if you start up in a place like Cange, there's no school. There was the beginning of a school when I got there. There was a school, but initially that school was outside, under a mango tree, with a banana-thatched roof. So that wasn't considered a worthy school. I was working with this Episcopal priest. I still work with him now all these years later. So there wasn't a modern school. There wasn't a clinic. There wasn't a hospital. There wasn't water. There wasn't electricity. There wasn't primary healthcare. There wasn't community health workers. There weren't trained teachers. So all those things would fit in the -- and there weren't jobs. That's another -- people need jobs, as I was saying earlier. You talked about disempowering a community. That word empowerment has been much abused. We misuse it all the time. To me, I would use it the way you did, is that people need jobs and livelihoods to be empowered, to be able to take care of themselves. So in that particular setting, as in much of rural Haiti, everything remained to be done.


Paul Farmer Interview Photo
What about a medical clinic?

Paul Farmer: There wasn't one. There was no clinic. But remember, I'd already been to many clinics and hospitals that were terrible. So that wasn't a good model. The one I saw, it was not inspiring. It took me many years to understand, and remember this is not me. You're asking about my story, but I worked with first scores, and then hundreds, and then eventually thousands of people in Haiti, almost all of them Haitians. And the initial community health workers who we recruited and trained together in 1984, they're all still working together. We still work together.

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This page last revised on Sep 28, 2009 20:07 EDT
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