I’m Dr. Paul Farmer, co-founder of Partners In Health, physician, anthropologist, and global health advocate. AMA!

You and I have talked a lot about what the world needs to do to prepare for the next epidemic. What’s your take on the progress so far? What’s gone well and what do we still need to do?

Picking up where we left off in this conversation not too long ago, there’s room for optimism and some for a bit of honest discouragement, too. Without a strong health system, the ability to respond effectively to epidemics is sharply limited because, regardless of who signs up to help, and from where, the formal health system is ideally the largest potential source for the staff, stuff, space, and systems needed in health emergencies. If after the wars in West Africa, which ended over a dozen years ago, there had been substantial investment in health systems strengthening, then Ebola wouldn’t have been able to mow through these countries, east to west and all the way from forest to coast, and the assistance of international bodies and NGOs and specialists would've been far more effective. One thing we need to do to prepare is to learn from what went wrong, of course, but also what went right. I have no doubt that people will look back at the massive investment you’ve made in polio eradication and note that in Nigeria, and other areas where that team and it’s partners were numerous and well supplied, this capacity could be rapidly diverted to the public health and surveillance work required to diagnose and track Ebola, as well as contacts. So the first task is how to steer attention to health systems and a care network like the ones in Rwanda and Central Haiti. The second biggest challenge in this work will be to avoid separating prevention/surveillance/control from care. This has been the downfall of many disease-control efforts across that region and that continent for over a century.

What is your opinion on the criticisms of foreign aid made by scholars such as Dambisa Moyo and Bill Easterly, who point out that no country has ever progressed on aid alone, and that not only is aid ineffective, but also harms economic growth?

I think that a critical scholarship about aid effectiveness is more than warranted; it’s urgent. Going back to at least Dambisa Moyo’s book: it’s probably true that no country has ever progressed on aid alone (but then again I don’t know of any countries that have tried); I don’t believe her point is that all aid is ineffective but rather that some of it is and ought to be made effective. Finally, since this category of aid lumps together the international financial institutions, I would have no trouble arguing that the structural adjustment programs of AIDS that were advanced as aid programs were deeply damaging to many African economies in the face of piddling investments in health care and education, which were shrunk even further as part of these programs.

Hi Dr. Paul Farmer,

It is truly an honor to be able to ask you a question. I am a first year medical student and I want to be a physician that serves those who don't have access to high quality health care both domestically and abroad. I am not sure how this will manifest (family? peds?) but I know this is what I want to do. I'm wondering how I might start to enter the field of global health care? I want to be conscious of the culture, language, etc and create sustainable care. How do you recommend physicians pursue a career in global health?

Thank you and if you ever find yourself on the west coast please consider visiting us at UA COM Phx!

Welcome to our world. You couldn’t have a better goal than the one you already laid out, and you don’t have to decide what path you’ll take (e.g., family, peds) in your first couple of years. Getting involved in global health equity will help you know what’s the best clinical training for you. The way you put it ‘to be conscious of the culture, language, etc’ is also spot on. I’m always disappointed when in medical schools and hospitals we advance the notion of cultural competence as if it were within the grasp of even anthropologists, forget about busy clinicians. What we should be striving for is cultural humility, which is a great building block for a career in global health equity. There are plenty of people at UA who are deeply engaged in this work and have been for years, and you should try and be part of that community no matter where you end up.

I've heard you are a fan of Lord of the Rings. What do you like most about LOTR and have any of its themes influenced your work?

I can't think of anything I don't like about LOTR. And certainly the themes have influenced my work because they have influenced the way I see and think about epic (as you might say) problems we see in our works. These are the problems faced by others, mostly living in poverty, and all of which could be lessened by vigorous and thoughtful accompaniment from us. I even slip oblique references into my books. What would Ebola be like without JRRT?

In 2005 you wrote a piece with Castro about how HIV/AIDS-related stigma in Haiti will decrease if people gain access to ARVs. Since then, anthropological research has shown that accessibility to ARVs in low-income countries has not, in fact, reduced HIV/AIDS-related stigma. Can you speak to your presumptions about stigma and causes of stigma in 2005 and how and if your conceptualization of 'stigma' has changed since then?

I’m not sure if you’re referring to central Haiti, but if you are, I’d beg to differ. There is ample evidence both of the conflation of “culturally reinforced stigma” and structural violence as manifests in barriers to diagnosis, treatment, and retention in therapy. This was always one of the biggest problems with the over-abundance of stigma literature. In central Haiti, where only 20 years ago many people were afraid to even utter the word AIDS, and now my PIH colleagues have done enough mobile clinics and surveys of asymptomatic people to make the claim that there are almost no more people in that part of the country who have not been diagnosed and not receiving care. There’s still plenty of stigma around any lethal illness and again this needs to be parsed from the stigma of poverty and exclusion, which is hard to do when treatment for AIDS does not include prescriptions for food, housing, education, and meaningful work.

Do you ever feel sad/depressed/hopeless because of injustice you see in the world? If so, how do you deal with it? If not, why not?

Hi /u/luminousVeil, Not very often. There’s probably no better insurance against depression caused by seeing injustice than fighting injustice. Looking at many of my friends from college who are successful in business, I know that they often face greater crises in meaning in their lives. We’ve brought many of them into our work with good clinical results.

Hey Dr. Farmer! I’m a student at UC Berkeley and a member of Partners In Health Engage at Berkeley and I had the amazing privilege of meeting you last semester when you came and gave a talk at UCSF during their global health bootcamp. I have a couple questions if you don’t mind!

• Do you think there are too many NGOs in Haiti and throughout the world, and if so, do you think oversight is necessary to prevent parallel programs?

• Is it necessary to get an M.D. to work in global health, or does an M.P.H. make more sense?

• I heard that you were coming to Berkeley for the Clinton Global Initiative University event in April! Would you have time to swing by to say hi to your PIH Engage admirers at Berkeley?

Also I was told that your book on the Ebola crisis was going to come out this Spring. Do you know when that will be?

Thank you so much for doing this! You continue to be an inspiration.

1. No, I wouldn’t say that there are too many NGOs. I’d say there are not enough good ones working in partnership with the excluded and with those who are supposed to be including them (e.g. health authorities). I do believe, however, that oversight is a good thing. I’m surprised in many of the places we work how few NGOs target their activities to enhancing those of public health and public education, nothing of public safety, public gardens, public you name it. In that way, NGOs can become part of a neoliberal trap that we should avoid falling into.
2. To your second part, no, it’s not necessary to get an MD or any clinical degree. In a previous post, I was singing the praises of biostaticians, and you can imagine how I feel about sympathetic managers, engineers, builders, or folks who link their business success to expanding opportunities to people living in poverty and facing sickness. So bring on the business folk, and the artists, and the bands--we need a big tent approach to global health.
3. How about you guys swing by to see me? I’m getting old.
4. I’m afraid that on the book front, I’m a little behind schedule. But I promise you I’m working hard on it.

Hello Dr. Farmer! I am an undergrad studying global health. I recently read Mountains Beyond Mountains and I am so intrigued by the efforts you made in Haiti, Peru, and Cuba. I am personally deeply interested in mental health issues and I feel that they are too often ignored in issues of public health and global health. In your global travels, what role do you think mental health issues play in the general health of society, especially in the developing world?

Hi /u/Nfsaleem -- Thanks for your question. As the slogan goes “there’s no health without mental health,” and I have yet to travel anywhere in the last 35 years where mental health issues haven’t been ranking problems faced by people living in poverty. They’re often the ranking problems. So I would encourage your interest. There’s a lot of recent activity to address the appalling lack of services available in settings of poverty and also to rethink the model of physicians as primary caregivers. Psychiatrists are so scarce in most of the places we work and absent in others. Nurses and social workers are also in scarce supply so we have to redirect our collective attention to these problems, invest more heavily in providing care and rethink the way it’s provided. This is a vibrant agenda for anyone with your interests.

Hello Dr. Farmer,

Thanks for doing this. My question: What do you think will be the most important single change we can make to address the physician shortage in the US that is projected to worsen in coming years as the population ages?

As an aside, I read Mountains Beyond Mountains as a kid. It has a big impact on me and influenced me a lot in my decision to become a physician. I start medical school next year. Thanks for doing what you do.

The more we physicians are able to focus on improving quality of care, access to care and integrating prevention and care the more we’ll want to be part of the teams that are necessary to address this shortage, this projected shortage. It’s not really just a physician shortage, it’s a health professional shortage and physicians have learned long ago that they learn as members of teams. Good team work with good outcomes and a chance to learn -- these are surefire steps to keep bringing some of the best talent out there into the health profession.

At a recent lecture, once again a student has incorrectly described Mountain Beyond Mountains as "his book." How done is Dr. Farmer?

A. 100% done B. 300% done C. So done D. He can't even

D

My wife and I are monthly donors to PIH, we were recently featured in the PIH newsletter which so far is the highlight of my year. I saw that you were doing an AMA and I just wanted to make you laugh. I know you get this all the time, but sincerely thank you for all that you do.

Thanks so much to both of you for the ongoing support (and also for the laugh). To your kind thanks, I’ll just say thanks for helping us be part of this work.

Dr.Farmer, It is so exciting to have the chance to speak with you and pick your brain. I am a student in NYU's global institute of public health getting my MPH in global health. It was my experiences of volunteering as a nurse in Haiti that changed my life. How can we improve the infrastructure of under-served areas without influencing them in a negative way? I am always afraid that I am doing a disservice when I volunteer my self to global health initiatives. I am afraid I cannot adequately hear the voice of the people who I am trying to help. What can I do to make sure I am being a truly useful agent of change? How can global stakeholders and NGOs do the same?

Thank you for being my personal hero. Pauline

Dear Pauline, Thank you for your lovely note. The best insurance against doing a disservice while volunteering is being afraid of doing a disservice. Since our professions encourage us to do no harm, I applaud your anxiety, but in measure. If you’re in and out in short trips, the best thing to do is to find a group equally committed to doing no harm and continuing to work with them over long years. Last weekend, I was seeing a patient in the same squatter settlement I went to in 1983, but the difference is we now do have the staff, stuff, and space, and systems required so that it wouldn’t have mattered if I had been there or not. Hearing the voices of the people you’re trying to help is difficult if you don’t speak the language and are not rooted in a specific community, but I get to work in places, from Russia to Lesotho, where I don’t speak the language nor have I lived in those places long-term. But it’s always possible to hear the voices by reading the work of others or seeking to learn from people who are in such privileged proximity to the afflicted. Another way of saying this, I know a lot about Haiti, but it’s better to know that you dont know alot about a place, and have to move forward with humility. That’s how I keep oriented in places I know less well than I know Haiti--that and working with a terrific team.

I am currently completing my last year in college and planning on getting a masters, and possibly a phd in biostatistics. My question is how do biostatisticians help improve global health, and is there a need for them currently. More generally I am very interested in global health but love math. What would be the most effective way to improve global health while still perusing my love of mathematics? Thanks!

Hi /u/Shmedler -- Don’t you go anywhere! We need quantitatively-minded folk in this work. And not just because it’s been part of a narrowly conceived donor strategy to come up with quantitative measures of relevance in global health. It’s also because any knowledge of how well we’re doing in responding to ill health requires a commitment to measurement. There’s plenty evidence that measurement alone improves the quality of the work. As an aside, my first recruits as the chairman of a department at Harvard Medical School were in biostats and epidemiology since we were weak in quantitative methods.

If you could take back a decision made by PIH in the past which decision would you take back?

Stopping a particular project prematurely. I’m not going to give specifics because people are too raw about it. But in my view, PIH should be the “House of Yes” and almost never the “House of No.” And the only legitimate reason for terminating any effort is if there’s no longer any need for our services.

Hi there! I'm a medical anthropologist interested in bringing community voices to the table during medical relief and aid, particularly to overcome barriers that may be culturally specific.

I was curious what your organization has done to collaborate with local non-allopathic healers to ensure patients feel safe sharing all they need for whole self healing, as well as what they might be taking already (preventing overdose/negative drug interaction/etc)? Also, does PIH use community health workers?

Second, do you think medical anthropologists really need clinical training (MD/NP) to be useful in the field with orgs like PIH? Do you have any without that training and, if so, what is their role?

Thank you so much for doing this. I'm really enjoying your current EdX course, as well!

Thanks so much for the question /u/Bluelotus313. There’s nothing I’m more grateful for than the chance to study both medicine and anthropology, although, I kept discovering, from Haiti to Russia to Peru to Rwanda, that many of the “culturally specific” barriers were in fact structural ones that could be seen across the world. These included extreme poverty, gender inequality, racism, geographic isolation, food insecurity, chronic low-level violence, and some pretty spectacular event violence, too. One of the ways that anthropologists can be helpful in this work can be to clear up confusion as to the real nature of barriers to a healthy life. As I noted in a previous exchange with a student, I don't think clinical training is required for people to be useful in an organization like PIH. Far more useful are cultural humility, ability to work well with a team that may indeed represent many different cultures and experiences, and persistence. To your other question, the majority of PIH employees are community health workers. Many of them have been what you term “non-allopathic healers” and some still are.Thanks so much for using the EdX course. For others interested in checking it out, here’s the link: https://www.edx.org/course/global-health-case-studies-biosocial-harvardx-sw25x-0

Fellow medical anthropologist here. When you say "access to healthcare", you mean "access to western biomedicine", which many indigenous peoples see as an example of imperialism and colonialism, rather than a "right". What steps do you take through PIH to ensure that culturally-appropriate health practices are implemented in partnership with community leaders?

Hey there, fellow medical anthropologist, I will just confess right here that I do mean “access to western biomedicine,” although it’s not so western since it’s not different than what’s practiced in, say, Japan and Australia. By underlining access to those living in poverty, we by no means seek to diminish the contributions or potential contributions of others held to be more “culturally appropriate” than any universalizing body of knowledge. My experience with self-described indigenous people has included rural Haitians who, of course, are not the indigenous people; they all died because of real imperialism and deadly colonialism. But limited experience in Mexico, Peru, and Guatemala has led me to conclude, by listening to my hosts, that they are very anxious to have access to “western biomedicine” even as they engage, as do most other humans, in seeking care from multiple and different types of healers.

Super big fan of yours Dr. Farmer! How do you think the work with PIH: Navajo differs from your work in other countries? Does PIH have any interest in moving into First Nation communities in Canada?

Hi /u/PublicInternNum1 Thanks so much. The feeling’s now mutual. The work in the Navajo Nation--through our sister organization COPE--is in some ways different than in the other places we work. Some places in Navajo have first world infrastructure. The topography looks like Lesotho, but the health care problems are much more reminiscent of Russia. And, of course, the history of the place is unlike anywhere we’ve worked. I know the team there has been working with Rosebud and has met with members of the First Nation in Canada and PIH-Canada is strongly supportive of this. Where this all goes will be up to others, but we’re excited about it.

What is your opinion of Remote Area Medical and other temporary clinic organizations? I have volunteered with RAM and can testify that the care is very much needed, however at the end of the weekend the community still lacks a permanent solution to the problem. Are Band-Aid solutions like this better than nothing, or should the resources go toward establishing stable clinics?

All of us struggle with this or a similar enough dilemma (for example, the debate about short-term medical missions). The answer to your latter question would depend an awful lot on the context. Are we talking about an area devastated by a tsunami or earthquake? About a recently cleared warzone? In these settings, I can’t imagine anyone who argue that assistance for the severely ill or injured is not better than no assistance. There’s little doubt, however, that investments in more permanent clinics as long as they’re accompanied by investments — in staff, stuff, and systems — are not only preferable but more likely to garner substantial support from other partners. When we finally bit the bullet and built University Hospital in Mirebalais — not a permanent clinic, but a permanent medical center — we had reason to hope that the largest donor for the first year of operation would be the Haitian Ministry of Health. And it was.

Thank you for doing this, Dr. Farmer! I signed up with Reddit just for this! After reading "Mountains Beyond Mountains" I have fallen in love with your work and dedication. I was educated through Kidder's explantion of you describing the difference in "managing resources" versus having well-manage health care, and your specific example of Cuba. What can the US learn about healthcare from Cuba? What would your "fix" be for the US healthcare system?

Thanks so much for your kind words. I signed up for Reddit just for this, too! Some of the things the US could learn from Cuba, and others from (say) Rwanda, are worth mentioning. Since it’s clear that we have a health care system that has turned into an illness care system, and that it has perverse incentives galore, a parlous financial structure, and although it’s definitely the place I want to receive care for serious injury or illness, it’s not, even at its best, a good system for chronic disease and worse still at integrating prevention and care. On many of these scores, Cuba has done better, and their health statistics reflect that, as do the low costs of their health system. Cuba is still very doctor-heavy, however, and on this score, Rwanda offers an important model for the United States and, indeed, for just about anywhere. Community health workers are the base of their care delivery pyramid, but they are committed to training specialists, nurses, and doctors, as well. There’s also commitment to universal coverage and health insurance schemes for all. This system, which is worth studying (and contributing to) is surely one of the main reasons that Rwanda has seen the sharpest declines in premature mortality anywhere in the world, and at any time. PIH has been really proud to be part of the Rwandan turnaround, and we wish for substantive improvements in US health care. I say this as someone who can think of no better place to practice than the Harvard teaching hospital (Brigham and Women’s), with which I’ve worked for over 25 years.

Hi Dr. Farmer. Thanks for your work for the poor - you are truly a real humanitarian, and thanks for taking our questions. How does your constant work around the world fighting for health for the poor impact your ability to enjoy family life, or do you manage to strike a balance between working and spending time with family?

Getting involved in social justice work and in health care delivery have been the greatest things that could've happened to me, I’m sure of that. And many of us can’t help but think what a different world we would be living in if our children were brought into this work early, and often. We’re lucky that our kids are deeply interested in this work, or engaged in it directly. There’s no one prescription, one size meets all, approach to engaging family and friends in social justice work. But there needs to be room for everyone.

I am an architecture student with an interest in global health, and I am planning on getting my masters degree in public health upon receiving my bachelors in Architecture. What role do you see architects playing in global health? What specific global health issues do you think can be solved with the help of architecture?

The reason I keep perseverating with this “staff, stuff, space, and systems” mantra, is because it's a mnemonic of just how much work there is do before we can even dream of delivering high quality health care to those facing poverty and disease. The space is question needs to be safe space, so who among us would not want architects, engineers, and builders on our side? You should read about MASS Design Group (https://massdesigngroup.org/) and Build Health International (http://www.buildhealthinternational.org) as we’ve been lucky enough to do a number of projects with them. Building safe clinical space is not a trivial matter as anyone dealing with tuberculosis knows very well. We didn’t get much help from architects and engineers in the first 20 years of our work, and we want to be sure we get plenty more in the future.

As a student now just at the beginning of my MD/PhD track, I wanted to first say thank you. Your books were one of the very first motivating factors for me to pursue medicine.

As someone very interested in rural medicine and generic drug development, my question is - when did you know that rural medicine was right for you? What was that first moment where you knew it was your calling?

A second question is, how can someone without a medical degree yet best volunteer in a meaningful way to improve rural healthcare

Thank you so much

Take that, Tracy Kidder! Someone reads my books. Seriously, thanks so much for reading them, and I look forward to reading your work, too. As far as rural medicine goes, the matter was solved when I ended up in 1983--prior to medical school--in a squatter settlement in Haiti. I’ve never had cause to regret it. Everywhere I’ve been, people living in rural areas have far less access to health services and so a preferential option for the poor in health care (the heart of PIH’s mission statement) requires paying attention to neglected areas. That said, I also get to practice in the city, in big urban hospitals, like the Brigham, and would encourage you to think about ways to leaven your time in remote areas, with some spent in urban areas, too. As mentioned before, there are many ways for non-clinicians to get involved in this work, while pursuing your own talents and interests, too.

Hi Prof. Farmer! We are your students in the University of Global Heath Equity Masters program in Rwanda - right now, we are in our Wednesday night Data-Driven Research Methods class discussing randomized controlled trials, and have a question:

How can we halt unethical research practices funded by big institutions? We've seen many examples of this, some as RCTs, and are not sure how to address it as future global health leaders.

Thanks and we hope to see you soon! ps. Dr. Agnes says hi

Hello there dear UGHE students! I wish I were right there with you (although I’d happily be spared any long-winded discussions about research methodologies). What a great question. I think that your role should be to be much more aware of this problem than we were as students, and to know the arguments inside out. Since these are just being laid out clearly in recent years, there’s no reason you can’t be part of the debate and the learning that could ensue. A second thing for you to do is to decline to be involved in unethical research that’s justified on the grounds of a specific methodology. You are, after all, the people who would be required to conduct such research, and many of you would be involved in design. A third thing you can do of course, is to promote the alternative—ethical, revelatory, and useful research on pressing health problems. Why not continue the trend started by many of you in Rwanda and at UGHE? Link your research directly to improve services for people living in poverty and to training opportunities for staff and research participants alike. Keep teaching each other, and the rest of us.

What are a few steps you'd like to see Janssen and Otsuka take to expand access to the new drug-resistant TB drugs that have recently been approved?

There’s a really good article about this in Boston Magazine (since I’m gathering from these exchanges that many of you are not familiar with the International Journal of Tuberculosis and Lung Disease). Let me just say this at the outset: we are so excited to have, after 40 years of drought, new medications, and these seem to be well-tolerated and easily administered. An organization like ours is concerned primarily with expanding access but that’s only one part of our mission. Another is to train people to use these medications and to develop new knowledge about them. Since the primary problem in drug resistance in the past has been adding a single drug to a failing treatment regimen, and other clinician-directed errors, it’s imperative that well designed treatment programs have ready access to supplies of both drugs at all times, and also to improve laboratory capacity since only a handful of labs in the world are yet in agreement about how to use these drugs in combination with others and to test for the infecting strains susceptibility to them. To be bold, one thing companies could continue to do is to join partnerships seeking to do all three things at once (treat, train, learn). I hasten to add that PIH has been working with them and learned a lot from our dozen years of partnership with Lilly and our collaboration with Abbott in Haiti. They got stuff we need, we got delivery capacity they need.

What projects will you be working on over the next 1-5 years?

My day job is as a Harvard professor, so I’ll spend plenty of time at Harvard Medical School and the Brigham and Women’s Hospital. Other than that, I’ll go anywhere PIH asks me to go. I can say that for me personally, I’m hoping to spend a lot of time in Liberia and Sierra Leone and also at the new University of Global Health Equity in Rwanda. A number of our sister organizations (ZL in Haiti, IMB in Rwanda, etc) are pushing for an agenda of formal accreditation for some of the hospitals and all of the training programs. This will take more than five years but is a labor of love for so many of our colleagues across the world. I’ve also been working hard on a book based largely on caring for and listening to Ebola survivors.

Hello Dr. Farmer, As you know, many families in Haiti struggle to keep their families intact. Many children, when they survive, are sent to live on the street, in restavek situations, or to live in orphanages. What are some of the most effective interventions you have either implemented or witnessed that have empowered families to be able to preserve their families and keep their children with them? Thank you!

Let me cheat by referring to previous posts in this exercise and say that here’s another example of a reflection of poverty and a lack of jobs and schooling for children in rural areas that too often gets transformed into a “cultural problem” native to Haitians. The best interventions are not hectoring or scolding poor families, but helping families send their kids to school and keep them in school, which is hard to do when Haiti has what is likely the most privatized school system in Latin America. That’s one of the reasons why it’s one of the least literate countries in Latin America -– structural barriers to meaningful employment for adults and schooling for children in rural areas. We work with a terrific group called Fonkoze in an effort to link their work to enhance poor women’s access to microfinance and financial skills and our work to take care of some of the sick children from these families and also even poorer ones. The joint program is effective but way too small and is called CLM (Chemen Lavi Miyò). Should be on Fonkoze’s website. If poor rural families are less poor, if it’s easy for them to send their kids to school and feed them when they’re not at school, if they have access to health care for their kids, if they have stable housing – they won’t be sending their kids off to be restavek.

Hi Dr. Farmer, I want to first thank you for all you do in both the fields of Medicine and in Anthropology. My question is this, how do we as providers stand against the movement to further commercialize and privatize healthcare? I'm particularly alarmed by what is happening right now in the UK, in 2010 the NHS had it's highest public approval ratings ever, now it's on the brink of collapse. What is our role in fighting for universal access and how to we move forward?

Thanks so much for asking this question and even more for fighting the good fight. Couldn’t agree more that health professionals should stand united in a full-throated defense of the right to health care and social safety nets. Yet in the past we’ve acted as professional guilds and our collective voices were too often raised in defense of ourselves and not the sick and excluded. Some might argue that’s the purpose of professional associations – to fight for its members’ rights – but I’ve always found this completely wrongheaded for the healing professions. I think we should stop doing that and start putting our energies into the fight for access, quality, value, and universal coverage.

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Part of me is grateful that you feel burdened by global poverty, because we should all feel that dread weight, and part of me worries that you haven't yet found the right way of making your contribution to this fight. It’s never done alone and so yours is a burden meant to be shared (not like the Ring). If you’re a student in a university, look around for PIH-Engage and other student activist groups; and keep looking for a community of concern, through which you can make pragmatic and sustained contributions.

Hello Dr. Farmer. In the book Mountains Beyond Mountains, Tracy Kidder recounted a time when you were replying to an email from a student. The student said they respected your work but couldn't do what you did. You verbally responded "I didn't say you should do what I do. I just said these things should be done."

Would you be able to elaborate on this point? I want to be a global public health professional one day but I want to better understand how to contribute in my own way. If I (or that student, or another person) shouldn't necessarily do what you did, who should do it?

I don’t recall the conversation, but then again that’s been some time ago--I could elaborate more now. It’s long been a practice of mine not to tell students that they should do what others should do. That said, whatever the topic of discussion may have been, it’s very likely we were talking about things that should be done by someone to alleviate suffering or prevent mortal peril. So I wouldn't take that back. A better teacher, which I try to be, would add that you should find out what YOU want to do to contribute to a universally-needed endeavor. As far as whatever I may have been talking about regarding what needs to be done, I’m guessing among those who should be doing them are health professionals, government officials, health focused NGOs, community organizations, survivors groups, etc.