We’re Dr. Paul Farmer and Ophelia Dahl, global health advocates and co-founders of Partners In Health. AMA!

Dr. Farmer, I run a tiny, but feisty NGO in Indonesia focused on stunting and rights for the poor. We talk a lot about the long defeat. I want to ask you how you deal with feelings of hopelessness? What advice do you have? How do you push past and bounce back when things seem hopeless? 

Paul: I work with my friends, and most of us have been friends for a long time. So the chances of us all feeling hopeless at the same time are much reduced. After the 2010 earthquake in Haiti, there were plenty of days when something akin to hopelessness washed over me. Obviously there was a lot of grief, since we lost many colleagues and friends, but we were always more than the sum of our parts in those weeks and months right after January 12. That’s the lowest I’ve been, and friends always shore each other up. But the real reason I distrust hopelessness is because when we’re talking about things like childhood stunting, in Indonesia or elsewhere, we’re talking about hopelessness on behalf of others, which they can ill afford.

Ophelia: That’s lovely PJ.

We very much enjoyed last fall the Q&A you did with Life's Library and we continue to talk about PIH often. A question some of us have been thinking about is, how does PIH approach sudden global health issues, like COVID-19 right now, but past outbreaks as well?

Ophelia: Very much the same way that we have approached the other epidemics in our midst, which is to say to make sure you have a robust health system in place. That’s to say having supplies, health professionals, and access to care. In areas where there isn’t that, make sure you work hard to put it in place. ASAP!

Paul: Adding a complementary perspective as an infectious-disease doctor, communicable pathogens almost always have some treatment and this disease would seem to have several. We’re not talking about the specific therapies, but rather the nonspecific ones, supportive and critical care. Since this is a communicable pathogen, protecting the caregivers is a prime concern. Once we link this to our mission to make a preferential option for the poor we’re going to find ourselves needing more staff, stuff, space and better systems. And that’s what our colleagues are doing from Haiti to Rwanda to Russia.

Ophelia: He’s pithy; you gotta give him that.

Paul: Hey, there’s a lot of experience packed into that blather!

First of all, thank you so much for everything you do at Partners in Health! I love following along.

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Second, in your opinion, what is the most effective way for a college student/young professional to make the world a better place for impoverished people around the world? Particularly in the context of having major financial and/or time constraints.

Ophelia: There’s no most effective way, but there’s your way. And I bet you already have a good idea about how to do that. I feel as though I stumbled into it by being open to what I saw and to listening and learning and then applying my own privilege to a series of problems with which I was not yet familiar. I would add that remaining optimistic and hopeful about the promise of your own engagement is much, much better than being or becoming cynical.

Paul: I would like to add that it’s precisely as a college student with major financial constraints that I got involved in this work that I find so compelling to this day.

Ophelia: However, he now has a credit card...

Hello, In your opinion how ethical are short term medical brigades that bring medicine and doctors from the US to rural areas of countries like Honduras as a way to expose students to global health and how can these brigades be improved to provide more sustained and longer lasting care? Thank you

Paul: I’d be reluctant to make a single diagnosis. After all, a short-term medical mission to correct cleft palates is not the same as week-long effort to introduce primary care in a country like Honduras. One is possible, the other not. And if non-surgical mission trips are conducted with local sister organizations who provide care 24/7, it’s possible to imagine that endeavor to be ethical, too. To go a step further, I would never discount the value of “exposing” students as long as they’re properly mentored and stay engaged. After all, that’s how we started...and we’re old now.

Dear Paul and Ophelia, many social scientists have produced incisive analyses about the current state of global health and poverty and about its historical, political, and social determinants. However, many such works often sit on the shelves and have limited reach, readership, or impact. As educators and implementers yourselves, what do you think we can do to improve social justice education? How can we make better use of scholarly contributions in education systems and policy circles?

Paul: Too many social scientists are timid about social activism. There’s no guarantee that social scientists are sure to become engaged in social justice work, which is one reason scholarly contributions are often scant. We should all ask the question the way you do, regardless of our professional training. Of course there will be pushback from students and colleagues alike, but there’s more often a real thirst to learn more about activism and engagement.

Ophelia: Maybe broaden the definition of what a teacher is, and what a scholar is, maybe even.

Paul: Now that’s going too far… How do you make a smiley face emoji in Reddit?

How exactly does covid-19 affect marginalized communities more? How do we make sure all communities get the help they need if that is the case?

Paul: Some of our friends have hypothesized that given the steady march of coronavirus in the United States, folks will be less interested in contributing to integrating prevention and care in other countries. I’m thinking, on the other hand, that the more people who ask the question you did, the more support--even moral support is important--will be forthcoming. That’s responding to your second question first. As for the first, the overly cautious will say, “well, we don’t know the answer to that question yet.” But there’s plenty to say. First, if the Wuhan patients I read about can teach us something, and they surely can, it’s that some substantial fraction of sickened patients will require intensive care. Many will require oxygen, IV fluids, and nursing care, and all will require food and TLC. Whether we call this “pragmatic solidarity” or something else, it’s what our partners are asking of us, and they’re spot-on.

Ophelia: We were reminded during the Ebola epidemic that more people died of Ebola than from Ebola. When a health care system gets shut down, people with other problems--from obstructed labor to viral pneumonia--don’t get the care they need. And many die. My worry is that the world’s attention will focus on one thing and will take our eyes off the prize.

I share Paul’s optimism, but I’m worried that we’ll focus only on those around us. We have ICU beds; some of the places where we work don’t.

Paul: Amen to that. That’s why case-fatality ratios are all over the place.

Compared to similar strains of the Corona Virus, what concerns you most about COVID-19? And do you feel as if the news outlets have helped or hindered when it comes to reporting of this outbreak?

Paul: The news outlets I follow have been very helpful. There’s also medical news, which is pertinent perhaps for the reason you mention--is this novel coronavirus more virulent or transmissible than the one that caused SARS in 2003? They’re genetically distinct, so it’s an important question. But giving all the credit to the virus is unwise, since humans create pathogenic circumstances (overcrowded jails, squatter settlements, failures to invest in health systems, etc.). It would be great to see more news about improving medical care as we continue to read news about containment efforts. There’s plenty of evidence from Ebola and other epidemics that the integration of prevention and care is the only way to roll. We shouldn’t have to beg for resources to strengthen health systems--or act surprised--every time there’s a scary epidemic.

1.SES is well-equipped to carry out intervention and epidemiological research, which is unusual among similar organizations. Do you think it's possible for nonprofits like PIH to support research in biological science and engineering as well? I understand it requires more resources and is less smooth to integrate with the usual operations. But community health workers and patients need new diagnostics, drugs, and vaccines; R&D scientists and engineers need to understand the needs they're addressing.

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1. Do you think LGBTQ people can live and work on global health among the poor long-term?

Ophelia: Right on, and it’s why we worked to build important and enduring partnerships with institutions like Harvard Medical School and Brigham & Women’s Hospital. A flexible nonprofit like ours is fit for purpose when it can collaborate productively with universities, or turn on a dime to address the kinds of issues that bureaucratic institutions are more sluggish to address. Actually there is a biosafety level 3 lab in Carabayllo and another one in central Haiti. These facilities were launched to improve clinical services, but will also generate new knowledge and basic science. Of course, LGBTQ people can work in global health. Everybody should be involved in this work. After all it was queer activists who led the fight for AIDS treatment for all.

How are you doing today?

Paul: We’re fine, thank you! Just reading a nice profile of Tony Fauci, who has been a staunch supporter of our work. His backbreaking schedule was much commented on, but in closing he said: “I’m not worried about myself, I’m worried about what this epidemic is going to do.” Or something to that effect. And that’s kind of how we feel.

Ophelia: I agree with that, which is typical for us after 30 years.

Paul: 38.

You guys are a huge inspiration to so many of us. How do you keep your drive and energy up for such large scale and arduous tasks?

Ophelia: Happily, we’re a big band across several continents, so truly, the energy and drive is constantly replenished. Paul: And energy is certainly heightened, or recharged, in the presence of students and trainees. Our mission and strategy call for the transformation of hospitals into teaching hospitals, and the establishments of universities. But even if they hadn’t, we would’ve found the students at the University of Global Health Equity and the trainees at University Hospital in Mirebalais inspiring and energizing. In fact, getting through the tenth anniversary commemoration of the earthquake was made possible by the news that University Hospital received accreditation from the same organization that accredits US teaching hospitals. https://www.pih.org/article/university-hospital-haiti-earns-global-accreditation-teaching-institution

So impressed by the work you two, and your organization, have done over the past 30 years.

What are your thoughts on effective altruism and providing the most care possible, rather than very expensive specialized care? Do you believe there is an opportunity cost to some of the care PIH provides?

Ophelia: I’m glad we didn’t rely on this calculus for our patients, and so are the patients! Seriously, we have found over these years that you don’t have to do just one of these things. If we believe in the human right to health, then it’s good to try to have the same high aspirations for our patients as we would for those we love.

Paul: There’s a huge opportunity cost to providing mediocre medical attention to poor people in rich countries, although that’s not the primary reason to stop doing so. As for poor people living in poor countries, in no other setting would you find, to use somewhat crass economic language, “more bang for the buck.”

Paul, you are my hero, and my favorite book of all time is mountains beyond mountains. As a healthcare worker, what should I do to protect myself and my family from this virus?

Paul: Wash your hands with soap! I know you know this, but study after study show that health care workers are unable to pursue a rigorous infection-control regimes without a lot of accompaniment, as we say here. They need personal protective equipment and adequate staffing to protect themselves as they care for patients, and that’s what we should do, and will do, in our own work.

Ophelia: Check out this article, which was just in Axios: https://www.pih.org/article/dr-paul-farmer-axios-remember-caregivers-amid-coronavirus-response

The Carrboro High students love book suggestions. Is there anything that you have read recently that you think we should check out? Thanks!

Paul: Hi Mr. Cone! It was great to see you and your students last week. I know your students have already read Just Mercy, but I’m planning to read it again before my family goes to Montgomery next month.

Ophelia: I tend to read novels when I want to distract myself. I thoroughly recommend Hilary Mantel’s trilogy. The third one is called “The Mirror and the Light.”

Hey Dr. Paul and Ophelia, thanks for doing this! As someone who will be starting medical school in the fall, what are some things that I can start to do as a student to help combat the inequalities that will inevitably be apart of my practice? (just finished Infections and Inequalities)

Also any tips for medical school and how I can be successful both in the classroom and in the clinic?

Paul: I can tell you that there’s always time for activism and combating inequalities, through multiple mechanisms, has never been more urgent than now. As we said earlier, we can’t come up with new ideas without the help of a younger generation. Here’s hoping you’re one of many in your med school class who are concerned with this pressing and pathogenic matter. In fact, it will span your work in the classroom and in the clinic. And there’s nothing quite like studying this matter as you’re moving between theory and practice. Thanks for reading that book. They’re not that easy to write.

Ophelia: And they’re even harder to read!

I am a middle school teacher. Do you have any tips on talking to 11-12 year olds about health issues like COVID-19? Some students are scared, some are amused, and some are apathetic.

In general, do you have tips or resources for helping middle schoolers become more aware of and sympathetic towards global health issues? I believe that some global solutions can start with sympathy and awareness in our youth, so I would like to do what I can to foster that.

Ophelia: We both have 12-year-olds and have conversations with them about our work. It’s their world too. I think 11- and 12-year-olds are actually more open and engaged than older people in talking about some important and urgent world issues.

Having conversations with them about these matters is important, even when there isn’t an emergency at home.

Paul: I think it’s possible to do this without frightening kids, and I think we have to understand that those who are scared or apathetic might be the very students who would most benefit from this kind of candor. We shouldn’t underestimate middle schoolers’ ability to understand and to be engaged--or the hard and generally under-rewarded work of their teachers.

Dear Ophelia and Paul:

What measures of justice should we push to address our complicity as U.S. beneficiaries of structurally-violent economic extraction—our public roads, education, health care—from historically oppressed peoples around the world (e.g. diamond mining in Sierra Leone)?

Bryan Stevenson: "The opposite of poverty is justice."

Paul: Reparations and reparative work are different. Many of us think that the former are overdue, and the latter is possible for anyone. Anyone can do reparative work, which is made possible by keeping the history of structural violence in mind. To your example, the diamond mining industry could have done more in the way of reparative work during the Ebola epidemic, but discussions of reparations would be better addressed to the United Kingdom.

What color is your toothbrush?

Paul: Whatever color they sell at Hudson News.

Ophelia: Gray and the expensive kind that removes tartar!

I love the story of Paul picking up Tom White at the airport for the first time. I heard that he was definitely someone that wanted to die broke. Do you have any other interesting stories about him?

Ophelia: Tom was endlessly interesting. In fact, today marks his centenary. And we miss him enormously.

Did you know he jumped in Normandy? He told us he was tipsy when he jumped. I understand why he might have been.

Thanks for doing this Paul and Ophelia. I’m based in New Jersey and we’ve just had our first coronavirus death here. I became extremely sick last summer due to smoking/vaping and had pneumonia in both lungs. I’m 24 female. Am I at risk? What is going to happen in the US? Will life be severely impacted? Thanks again!

Paul: It’s our pleasure, and sorry to learn you were sick last summer. Am assuming you recovered from pneumonia and would hope and expect that there’s no lasting damage to your lungs. I do think the United States will be “severely impacted” but also believe we have the wherewithal to say to even the most vulnerable, “we gotchu.” And that’s before we have proven antiviral therapies and vaccines. If anybody can weather this illness, it would seem to be otherwise healthy young people. For those who fall severely ill, this is a place in which we have a pretty good safety net for the critically ill and injured. It lacks coordination, it can be slow, it’s unevenly distributed--but it is staffed by really competent nurses (and some doctors) who know how to deliver supportive and critical care.