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Remembering Paul Farmer, a physician and global health care champion

DAVE DAVIES, HOST:

This is FRESH AIR. Paul Farmer, the physician and anthropologist known for his long-standing efforts to bring health care to some of the poorest people in the developing world, died Monday in Rwanda on the grounds of a hospital and university he helped establish. He was 62. Partners in Health, the global organization he helped found, said he died of an acute cardiac event. Farmer worked on public health projects in many countries, developing strategies for dealing with tuberculosis, HIV and Ebola, in addition to providing basic affordable care.

When The New York Times contacted Dr. Anthony Fauci about Farmer's death, he wept in the interview, saying he and farmer had been like soul brothers. Farmer had long-standing ties to Haiti, where he founded a clinic decades ago that would grow into a network of six medical centers around the country. We have a short excerpt of my interview with Farmer in 2011, after he'd been deeply involved in efforts to help Haiti recover from a devastating earthquake the year before. He'd written a book, 1 of 12 he authored called, "Haiti After The Earthquake."

(SOUNDBITE OF ARCHIVED NPR BROADCAST)

DAVIES: Now, of course, one of the things that you note in the book is that improving health conditions in an impoverished place like Haiti is not just a matter of will and medical effort. It's a matter of dealing with, you know, the surrounding poverty and underdevelopment of the economy. And you write that the government of Haiti was often ignored by international relief agencies and nongovernmental organizations. And you say it was known as the Republic of NGOs, meaning there were all of these aid organizations, all of them working around and ignoring the Haitian government itself, and that over time, that undermined everyone's efforts. Give us an example of this and why it is harmful.

PAUL FARMER: Well, let me give an example that self-critiques because this is another thing I've learned in trying to write critically about NGOs is that umbrage will be taken. And even the most constructive critique is difficult to get out there, in part because a lot of NGOs are defensive in posture. And I think you could do an analysis regarding why this would be so. They're struggling for what they regard as scarce resources. I understand all that.

So to use our own example, Partners in Health has been working in in Haiti for 25 years. In the first 10 or 15 years, I would say that we've got a lot of good work done with our Haitian colleagues. Again, this is all Haitian led, built up an organization with the Haitian leadership. All the employees were Haitian, providing good medical services or at least decent ones, but to a fairly restricted area.

And we saw that as our medical efforts grew, at the same time, a lot of the public sector medical programs were failing in the same area. And so about 10 years ago, we said, well, what if we end up being guilty of what we're criticizing? That is allowing the public health sector to collapse even as we grow. What if we're also guilty of that? And how could we make plans - plan better so that we end up reinforcing public health and also public education?

In Haiti, what had happened was the public sector was weak and underfunded, and people talked a lot about corruption and inability to get things done. And so they'd build these parallel systems, the NGOs - hence the Republic of NGOs. So what we did 10 years ago - and I'm - was to decide that all of our expansion would only occur in the public sector. So what that meant would be we wouldn't build our own hospitals or clinics but rather rebuild or build public sector clinics and move our staff into those clinics and facilities and try to beef up the public sector that way. So this is not the only way to strengthen public health and public education in Haiti. It's just one way. And we have encouraged others to join us in this and make it less of a cosmetic effort.

Now, after the earthquake, ironically, that argument got harder to make because the public sector was precisely the group most affected by the earthquake in terms of personnel, number of lives lost, but also infrastructure. So now it's even of greater challenge to work effectively with the government, and yet, it's even more important to do so.

DAVIES: Help us understand why it doesn't work for private aid agencies, NGOs, to come in and build their own network. I mean, if you go into central Haiti and build your own clinic, you hire Haitians. You treat Haitians. You do good things. Why isn't that just as good as the government doing it?

FARMER: Well, you know, it can be just as good. But take the example of cholera again. Cholera exploded, as I said, like a bomb. It also exploded in some of the very areas where we were working hardest and longest. And that is not because we weren't aware of the importance of clean water; it's that the NGO sector can't replace public works - and not in, you know, Philadelphia or Boston and not in Rwanda or Haiti, either. So for some services, you can have service providers that are not public.

I mean, the Harvard teaching hospitals where I work are private, not-for-profit hospitals. So I'm not making some ideologically driven critique of private sector engagement. It's just to say there needs to be some public safety net. And I think that's especially true for the poorest because, after all, an NGO doesn't have a mandate, a legal mandate, to provide basic access to health and education and clean water for the citizenry of Haiti or the citizenry of Honduras or the United States, really. That's a public sector pact to provide these services.

The majority of education in Haiti, probably 85% of primary and secondary education in Haiti, is private. And I think it's not an accident that that system is so privatized, and Haiti is also the country with the highest rates of illiteracy in the hemisphere. So there's this connection, I think.

DAVIES: It also strikes me that you're somebody who's been really effective at building effective, you know, medical treatment facilities in a lot of places. And in this role, as a U.N. special deputy envoy, you're having to tackle the bigger, broader stuff, economic development issues - I mean, how you govern a country. You going to stay with that? Or do you want to get back to something that's more in your field?

FARMER: I would very much like to get back to direct delivery of medical care and, really, to focus on rebuilding in the health care sector and also in training physicians and nurses. I am full of respect for people who try to take on these big development questions inside government and outside. And - but the satisfactions that one gets in direct service are quite gratifying, emotionally and personally. And so, I think, for me, you know, making sure that there's enough of my time spent on teaching and delivering care is really going to keep me in this for the long run.

And I think most of my co-workers, including my Haitian co-workers, feel the same way, that sometimes when the big picture is just overwhelming or daunting or discouraging, there's always the possibility of the little picture that is responding to a problem. I mean, it's not like cholera is a little problem. Cholera is a huge problem. But it is within our reach, I think, to improve the quality of services offered to people with cholera and the quality of preventive services in a region. And so I'm going to try and do both those things, and many of my co-workers are doing that as well.

DAVIES: Paul Farmer recorded in 2011. Farmer died Monday. He was 62.

Coming up, Justin Chang reviews the new film "Cyrano," a musical based on the Cyrano de Bergerac story starring Peter Dinklage. This is FRESH AIR.

(SOUNDBITE OF HILARY HAHN AND CORY SMYTHE'S "LIGHT MOVING") Transcript provided by NPR, Copyright NPR.

Dave Davies is a guest host for NPR's Fresh Air with Terry Gross.