(audience applauds)
- Welcome everybody to
the David Rubenstein
Distinguished Lecture.
Our lecture tonight is with Paul Farmer
on the topic of The Future
of Global Health Equity.
And Paul Farmer, he doesn't
really need an introduction,
he has a long history
working together with Duke,
serving on the Board of Trustees,
and so we're so pleased
that he's come here to join us tonight
and share some of his insights with us.
The Rubenstein Lecture is
endowed by David Rubenstein,
who also doesn't need an introduction.
And David actually will himself be here
on 13th April to give another
David Rubenstein Lecture,
so I hope you'll come
out for that as well.
I'm Judith Kelly,
and the Dean of the Sanford
School of Public Policy,
and our mission at the Sanford
School is to improve lives
through teaching, research and engagement.
And so Paul Farmer's life
really is a testimony
to everything that we
aspire to as a school.
And I had the privilege earlier today
of recording a podcast with Paul Farmer,
and I think you are in for a treat today.
His life really is a story
of ways that we can have an impact,
real impact on the world
when we work together with other people.
Our lecture tonight is
done in collaboration
with the Center for
International Development,
as well as the Duke
Global Health Institute,
so I thank them for their partnership.
I would like to welcome now onto
the stage Paul Farmer and Menoush Mohana.
(audience cheers)
(audience applauds)
- Thank you.
- Menoush is an Associate Professor
in the Sanford School of Public Policy,
and he's a scholar of public health,
and he studies the delivery
of healthcare in developing
country contexts,
and he's actually joining us today
from his sabbatical in India,
so I'm very pleased that he's made
this journey just to be with us today.
And Menoush studies,
some of the things he studied include
what is termed the no do gap,
which is about how in
India and other contexts,
even if doctors know
the right treatment today may
not always be prescribing it.
So this idea that there is
a gap between what we know and what we do,
which incidentally also describes
my relationship with chocolate,
but I don't think that's
what he had in mind.
(all laugh)
So welcome, Menoush.
- [Menoush] Thank you so much.
(audience applauds)
- I've already shared with you
a little bit about Paul
Farmer's impressive resume.
Paul Farmer is a medical anthropologist,
and a physician,
and he really has dedicated
his life to improving
the health of people around the world.
He is the founder of Partners in Health,
he also it is a medical doctor
at the Harvard Medical School,
he has an appointment
at the Brigham's Women's
Hospital in Boston,
both of these places he
holds leadership positions.
In addition to that he also has just
helped co-found a new
university in Rwanda,
and on and on, I could go on,
and if I kept going on
there will be no
distinguished lecture at all,
because you would just listen to me.
So I'm going to stop and welcome
to the stage one more time,
if you will please give
a round of applause for Mr Paul Farmer.
Thank you.
(audience applauds)
- Thank you so much Judith
for that warm welcome.
And hi everybody, it's
wonderful to be here,
and Paul, thank you for giving us
this opportunity to have you here.
When Judith asked me if I'd be willing
to come all the way from India,
it took me maybe a few
seconds before I said yes,
this is a wonderful way to
come and meet you and be here.
- I hesitated more than a few seconds,
because I was scared about
talking in Page Auditorium.
- I hear this is where you
come for rock concerts,
now we have an audience that's
befitting for a rockstar,
so this is great.
- I was telling Mary--
- I know that John Bolton
was the last speaker.
(audience laughs)
- So since you came just
last night from Rwanda,
let me start from there.
You've been working in
Rwanda for a long time,
and you are the Chancellor
and one of the co-founders
of the University for
Global Health Equity.
So why don't we start with that?
Can you tell me what it really
means to have a university
that is focused on global health equity,
and more importantly,
what do we as Duke, learn
from what we are doing
in global health equity there?
- Well first I should say
that to be the Chancellor
is just a figurehead role.
That was to make you laugh,
but it's also true.
The real leaders are also
people that you know,
and I will take just a second to mention,
Agnes Binagwaho, who you already know,
who is a pediatrician,
she was Minister of Health
for Rwanda for five years,
and she led the National
AIDS program before that.
Just a great and inspiring figure.
The Dean of the School of Health Sciences,
David Tumusiime, who is
an Ethiopian surgeon,
and they have assembled
a terrific faculty,
but the students are reason enough
to be excited about it.
The logic behind the University,
I would just say as a participant,
one of many participants was
if you could remake the modern university.
You think about this university,
which did so much for me.
How can you have a great university,
whether it's in Boston or here or anywhere
where there's, let's say, Jim Crow,
you really can't,
you have to have a university based
on inclusion or it'll never
be a great university.
So part of the answer to
our rhetorical question
what would it look like
to redesign a university
focused on equity from the very
beginning, from the get go,
that was really the driving logic,
and obviously you need to find
resources to build a campus,
you have to decide where
it's gonna be sited,
what its primary activities are gonna be.
And that was an exciting,
that's not the right word,
but it was an exciting prospect.
But I think again,
the real function and meaning
of it was revealed by
the students themselves,
and they come from all over the world,
the medical students are all from Rwanda,
mostly young women,
but they will be from
all over in due time.
And I am mention the University
because you let me mention it,
but I hope that people here,
students, faculty, staff,
will think of the University
of Global Health Equity,
as part of our network, your network.
And I've never been
able to say that before,
I can't say well, I want you
to think of Duke as your university,
or I want you to think of Harvard,
I'm not authorized to say that
but it feels really cool to be able
to say that about a university.
- Even as co-founder you're not allowed?
- I am allowed, oh yeah, and I'm saying.
You're all welcome, come join us.
- Excellent.
- I'm getting some amen's
here, and I love it.
Just continuing with Rwanda.
- I'm getting less nervous by the way.
Page Auditorium.
- Very soon you could pick
up the mic and start singing.
- I will.
- There you go.
- John Bolton and I are doing
a duet in about five minutes.
- It's not me.
So continue with Rwanda.
- Poor Menoush, he comes
all the way back from India
and doesn't know how to handle the--
- I can't do two acts,
I can only do solos.
So one of the things that
Rwanda and global health,
Rwanda has managed to do
a lot in terms of improving
its health outcomes,
health service delivery
and has got a lot of attention for that.
Much of the attention also partly is
because of the work you have been doing
in the health space in Rwanda as well.
So when you step back
and the Global Health
Audience looks at Rwanda,
what do you think are the challenges in a,
adopting the changes from Rwanda
and scaling it up to the global context.
And if you'll indulge me,
I think I should also
point out to the audience
that Rwanda is not exactly a tiny country,
the population is about 13 million.
It's the median size of
all countries in Africa,
and also all country globally.
That's roughly the median
size of a developing country.
So lessons from Rwanda can be transported.
But how, and what challenges
do you think we might face
in adopting some of these?
- Can I tell a joke first?
- Please.
- It's not a joke,
but as you were singing my praises,
I just came here from Rwanda,
and let's just say an
eminent figure there,
it wasn't Agnes, because
she was out of the country,
but anyway, it doesn't matter who it was.
The day before yesterday,
he or she is said,
Paul is never right.
Just as a statement, that hurts you know,
I'm right sometimes, just by chance.
- [Menoush] Sometimes.
- Sometimes.
How do you transfer lessons
from one place to another?
You do this, I do this, Judith does this,
you try to say what is
the specific and what
is the generalizable?
And I say you.
Rwanda is in a special position,
at least in my experience on
that continent and beyond,
people are starting to know as you said
about Rwanda's progress,
and really reversal of trends.
Over the last since the genocide,
and this is not something
that we talk about that much
in the course of our
everyday work in Rwanda,
I don't.
Since that terrible time
Rwanda has sustained amazing progress,
whether you look at the standard
measures that we all do,
infant mortality, maternal
mortality, juvenile mortality.
Case mortality rates
for certain illnesses,
Rwanda has shown the steepest declines
in mortality ever documented
anywhere at any time.
So already just this basic
fact, if it is a fact,
and I think those numbers
are pretty well vetted
and they come from multiple sources,
but if that's a fact,
one of the things,
the University and its
faculty are the students are
also examining is what
accounts for that improvement?
And of course there are local variations
in one district to another,
but this is a field of
study that in a way is new,
because it's not just
epidemiology, biostatistics,
it's really asking what impact
does care delivery, prevention,
how do these account for
these changes or not,
there are lots of other possibilities,
but the actual study of
that is what's going on now.
The lessons, I could
just use as an example,
if you compare let's say outcomes
for patients who were
diagnosed with HIV disease,
and those who are, you've
written about this yourself,
this cascade, people are
diagnosed, started on therapy,
how many have evidence of improvement,
viral suppression in this case,
a year out?
Rwanda outperforms
an urban America cohort
very significantly.
So let me put it another way,
the outcomes of age therapy
and tuberculosis therapy
are better in Rwanda than
in urban American settings.
So if we can say why,
and I think we can start to say why,
it's a publicly funded program,
it has social supports,
and it's delivered with
the help of community health workers.
If those are three reasons,
and again, their order may be disputed,
then why can't we do that here?
Why don't we have a robust cadre
of community health workers
here in the United States to help us
and people living with
chronic medical conditions,
which is really a very substantial chunk
of the world's population.
And that's something that
we've been trying to do,
is take some of those successes,
and whether you call
it reverse innovation or something else,
how do we take some of
the lessons learned there
and apply them here?
And I think that again, this
is another avenue for action,
but also for study, how
well does that work?
- [Menoush] The transmission?
- Yeah, and again,
what motivates providers whether
they are physicians, community
health workers or nurses,
what motivates them and how do we
and they sustain those efforts?
Again, whether we call
this implementation science
or delivery science or
whatever term we may use,
it's an important area of study,
and not one that we
studied in graduate school
or medical school, at least I didn't.
- And something around provider motivation
is very much something
I've been pursing myself,
and I do have a question on that,
but I do want to go back a little bit
in your response you
talked about how Rwanda
in particular has been seeing dramatic
improvements in terms of health outcomes,
whether it's fertility rates,
child survival, and so on and so forth.
Even globally we have seen
many of these improvements,
yet we found ourselves we are
far short of our sustainable
development goals.
And one of the possible reasons
why this has not happened,
is that there is this
problem in where people
receive healthcare, and
what kind of healthcare.
So when I talk to policy health makers,
especially in countries like India,
where about 70% of people receive care
in the informal sector,
the challenge has been that
the traditional public health push
has been to say let's train more doctors
and sent more doctors into rural areas.
While the reality is about 70%
of people receive care
from the informal sector.
And so this divide is really
hard to bridge right now
and one possibility has
been to try to up skill
the community health workers
or the local healthcare providers,
but we faced a lot of resistance
from the established
medical establishment.
They actually feel threatened,
the MDBSM doctors feel threatened
when you say let's go in with
community health workers,
or low skill workers to deliver care.
Because frankly you don't need 5 1/2
or six years of medical education
to deliver basic healthcare,
which can save lives.
Have you?
- This experience, just to be anecdotal,
is that permitted in Page Auditorium?
- No, you need a provision.
- Yeah, I need a permission slip.
I was at a conference in,
how typical is that as
an opening statement
by an academic, I was at a
conference in Kampala, Uganda.
It was on mental health.
And I was schlepping back
to Rwanda from somewhere,
and I gave a presentation,
not about any specific mental
health problem or epilepsy,
but that was the charge,
so I was using an example.
This was about 10 years ago maybe,
I was using the example
of HIV care in Rwanda,
which requires as I'm sure you know,
requires ongoing therapy,
like diabetes or major
mental illness often do.
And I was presenting, doing my shtick
as they say in scholarly terms,
and a professor, I remember
he was from Nigeria,
and I think maybe a
professor of neurology.
And I was making a pitch
for community health workers
and up-skilling them as well
and supporting them more.
And he got up and said well you know,
this is all very well and good
for you to say about rural Africa,
but you would never advocate
that for your own country.
And I said, here's my chance
to say oh yes I would, and do.
This is meant to be a prescription
for chronic medical conditions,
which again, most of what we see,
at least I'm an internist,
so I would say 90% of
what I see are not acute
injuries but chronic problems.
And that is the guild mentality
that you are describing,
is it's been threatening to
professionals, some of them,
which is bizarre in a
way because it's not like
community health workers
are really angling
for the jobs of sub-specialist positions.
And I think this is just something,
that was 10 years ago,
I think it's better now
I think it would be better in coming years
I think there will be more understanding
of community health
workers fit into a system.
And personally I said
this, and you did earlier,
I am actually a tertiary
care sub-specialist,
who works all the time in hospitals,
the advocacy for
community-based interventions
and community health workers
is not based on my interest
or my experience or my clinical practice,
but on the need for us to have
an effective response to chronic ailments.
- And some of the ongoing
innovations in care delivery,
whether it's through telemedicine
or franchising models,
which work with some
of these community health
workers have a lot of promise,
but the adoption from
the medical establishment
has been less than what you would hope.
- Yes, so far, but I'm an
eternal optimist about this.
If you can keep showing, of course
it's frustrating to have
to keep showing something
that's obvious, but if
you could keep showing.
What I should have said
to that neurologist was,
you have patients with epilepsy.
Epilepsy as you know, but
maybe not everyone here knows,
is a highly lethal disease
in much of the world.
Deaths by drowning, burning,
it's just an awful thing.
And yet if you're on therapy,
antiseizure medicines,
you don't have seizures.
And there have been studies,
one of them done by a Kenyan colleague,
he's a neurologist, he just took X number
of patients with a diagnosis of epilepsy,
seen in a Nairobi neurology clinic,
so that's already the great majority
of people with this
disease would never have
the diagnosis or be referred
to an urban medical facility.
He just said, of this X number of patients
who are on antiseizure medications,
how many of them have therapeutic levels
of the drug in their blood?
And I may be getting the numbers wrong,
but basically what he
described to us was that,
0% had levels that were too
high, super therapeutic,
something like 20% had
appropriate levels in the blood,
so called therapeutic levels.
And all the rest had
some therapeutic levels,
or zero drug in their blood.
So these are patients with a diagnosis,
with a prescription, et cetera.
And if you could take community
health workers and say
let's try this with
community health workers.
So whether you're looking at blood levels,
adverse events, meaning
someone having a seizure,
you're gonna show that this
is an effective model for that disease.
Again, it's a lot of
lives lost along the way
to be arguing this but I think we have
to keep marshaling the proof.
- Another aspect of this problem of having
an adequate number of doctors
in these areas is the issue of migration.
And we frequently hear from, especially
from the anti-migration
camp saying that this is,
I have read editorials and talk about
it as a crime against humanity
and so on and so forth.
I recall a conversation with one
of the deans of the universities in Ghana,
and he was really upset
about migration of doctors.
And I asked him, do you know
about migration of engineers from Ghana,
is this something you worry about?
No, I don't care.
I said, maybe the problem
is you don't have enough engineers,
if you had more engineers
and more scientists
and more economists in
Ghana, not that economists--
- No more economists.
- No more economists, enough of those.
- Those guys are useless, right.
But if you had more engineers
to build better roads
and better hospitals and better bridges
maybe you wouldn't need as many doctors,
and maybe you would be able
to retain more doctors.
He was obviously offended,
but I do think there is something
to be said about migration,
we think about migration of health
personnel as if it's an isolated case.
But it's not, doctors are
humans too who would want to go.
- You know, I had some
epiphanies about this years ago,
and again, a lot of the
lessons that I'll mention,
for me they come from Haiti.
Which I went to right after leaving Duke
and before starting medical school,
so with zero skills and a lot
of delusions about my value.
In fact the first decade was like
I was wasting other people's time.
That's a long time to be a failure.
- 20 years.
- Yes, but the more recent
decades were better.
(audience laughs)
But I was not resentful
but something close to it,
of the Haitian professionals
who were at my room,
remember this is in the 80s and 90s,
and that was a dumb way to feel,
why would I feel resentment
that as you said,
professionals are humans too,
at least the data suggests
that professionals are human,
we have some basic research to be done.
And what I came to learn
over the years was,
first of all the idea of
governing where people migrate,
well let's just say that didn't happen
to my forebears from Ireland,
no one was telling them not to go.
But the idea of having forces
that would prevent
professionals from migrating,
I think that's not only stupid
but not really morally tenable,
I mean we wouldn't apply it
to ourselves as you were pointing out,
but the idea of pulling
people back to need,
with the staff and stuff and space,
meaning clinical space that they need,
that's the way to roll on this.
You want nurses and
physicians and engineers
to be in a place,
well why do we have so many of them
in rural Rwanda at this university,
because we haven't paid attention
to the kinds of things they're asking for,
and they're asking for the same things
that we are asking for here,
decent wages, good working conditions,
and a delivery system that actually works,
and I can tell you in Haiti,
not only have we not lost
our physicians and nurses,
when they have migrated,
it's been to Rwanda,
Malawi, Lesotho, Liberia,
and Sierra Leone.
They are working in a system,
whether we built it or not,
where they can be effective.
And I have enormous regret
for having had that silly idea
that we should prevent
people from migrating,
and a deepening affection for the idea
of making good working
conditions for the professionals,
so they could serve those who need them.
- Actually two comments on that,
one is that there is new research
that shows about migration in particular,
that one of the most productive things
that we can do from
a public policy perspective
is lift migration,
because when migrants come in,
the amount of productivity
that they bring to the
economy is many manyfold,
so the spillover effects are massive,
and we're seeing new evidence on that.
- 15 % of African-American physicians
in the United States are Haitian.
- Is that right?
- I think so.
- Oh, wow.
- And that's enriched,
and I'm just taking physicians in Haiti,
but that's obviously,
I wouldn't want to run a
Boston teaching hospital,
a Harvard teaching
hospital without Haitians.
Bad idea.
That was also to make
you laugh, but it's true.
- I don't know how Boston
teaching hospitals run, do they run?
- I like them.
- You like them.
- Judith was born in
the Brigham I believe,
no, her child?
- [Judith] My children.
- Your children, my father was too.
My children too.
Sorry.
- I hear it's a good place.
- It's a good place.
I'm still nervous about Page Auditorium.
- And you know earlier they wanted
to turn off all the lights,
when we were trying out
the light settings here,
and it was gonna be pitch dark there.
- It's better pitch dark.
- No I was worried
everyone would fall asleep.
- I'm less nervous.
- And I said let's not do that.
But I was gonna point out the second thing
you mentioned about creating
the right environment,
and this is an area where sadly
we don't have enough evidence.
But given that in
healthcare in particular,
the people who come into healthcare,
the nurses, the doctors, the
community health workers,
these are folks who are intrinsically
motivated primarily to
do something to help.
When these folks are in settings
that they can't really do
what they're trained to do,
you lose motivation.
- I would leave in a minute.
That's the other thing is,
good working conditions,
some of the things we've found,
and again I wish I could
say this is some master plan
approved by the Sanford School
and disseminated as policy.
Again, a joke.
To retain our professionals,
but another thing is, the
chance for ongoing education.
Not just to be trained,
but to train others.
That's another huge factor,
you build a teaching
hospital in rural Haiti say,
or rural Rwanda,
and you see how many people
you can recruit and retain,
it's a lot.
Because again, they want
to be part of this process
of inspiring other people,
taking good care of patients.
And that happens best I think
when there is that kind of environment.
Again, where they have decent
salary, decent conditions.
When I went to Malawi, this is 2006.
The first thing in a rural area,
the first barrier that we run into,
there was no hospital in the district,
so you could say that
was the first barrier.
But I've been in hospital
free districts before,
but there is even fewer
Malawian health professionals
per capita probably,
certainly than Rwanda now.
And one of the things we
heard again and again is,
we will go there when
there's decent staff housing.
It wasn't the first time I had heard it,
and we built decent staff housing,
because we wanted to recruit and retain
The professionals, and again
this is in a rural area
with no hospital at all.
So then we had to build a hospital.
But the first thing that they
wanted was decent housing.
- Which seems very reasonable.
- If you can get out of that mindset,
if I get out of that mindset
as a young professional,
of thinking well, why should we bother
with the housing of the professionals,
we're here to serve the
patients and the destitute sick,
that logic is okay,
but it's not going to
be what turns the tide
in terms addressing some
of these human resources
four health needs.
- And actually just
building on that last point,
here is another issue is for
a long time global health,
especially the medical
aspect of global health
was involved in training physicians
in developed countries like the US,
and then there was medical
tourism where you would go,
I think actually Sian
had a different turn,
no Modu Pye was using
this term, fallen tourism,
medical students would volunteer
and go perform surgeries
or whatnot and come back.
- Was that bad?
- No, it's a perfectly good idea,
it's like got frequent flyer
miles and hotel points.
- Cardiac surgery.
- There you go.
- I did that, I didn't do that by the way.
- That worked.
So my point was,
it doesn't leave enough capacity,
you could spend all your resources
on training students and sending them
there but it doesn't create the capacity.
The other model which you are alluding to
is to create capacity
for delivering services
in local areas is not that easy to do.
So there's been some notable exceptions,
so Brack has been touring some of that,
the University that you're talking
about in Rwanda has been--
- Well even if I may, to return to Haiti,
and I hope there are some Haitians here.
The experience of the
earthquake 10 years ago,
I don't even like talking
about it actually,
still to this day,
it was the 10th anniversary last month.
But by then 2010,
we had been collectively working,
this is a Haitian organization,
and we had a number of,
we had a lot of,
I was in Haiti at the time,
but I found very quickly
that we had a lot of
unsolicited donations,
which is kind of exciting right,
it never happened to us before.
And I'm talking about millions of dollars,
more than half of American households
I have heard contributed to
earthquake relief in Haiti.
Now, it didn't add up
to what it should have,
but I can tell you what we
did, again as a collective.
The training institutions of Haiti were
as you know concentrated
in Port-au-Prince,
which was the epicenter of the earthquake,
so they were destroyed,
the national nursing
school, the medical school,
the teaching hospitals.
Many of you were there, or went there.
And so there's no way to
train nurses and doctors
or no straightforward way
if all the buildings are lying in ruin.
And they were.
So it was in between,
I was in a quick zone seeing patients,
but I knew that this money had come in.
And our team felt that
what we should do with it
is build an academic teaching center,
a teaching hospital
for nurses and doctors.
And I remember the skepticism
that greeted that proposal,
and it didn't come from Haitians.
It came from experts.
Experts in disaster relief,
experts in development.
And there was one,
and this was like I said,
it wasn't a Haitian,
does that shot you that
it wasn't Haitians,
that said oh no, we don't
need a medical center,
of course it doesn't shock you.
But I don't want to
specify the nationality
of this person or the
gender, but she was French.
(all laugh)
And this is about six
months after the earthquake,
and she was in a position
of great influence,
too great I might add.
And said this is not the time
to be thinking of building
an academic medical center in Haiti.
And I went, wait,
so all of Haiti's academic medical centers
have been reduced to rubble,
the national nursing school almost
no third year students
survived, or the faculty.
I mean, like it pancaked.
And I said, well, if it's not a good time
to think about building an
academic medical center now,
when would it ever be a good time?
Unfortunately we didn't
need to ask permission,
because donors had given us the money,
and the Haitians weren't against
it, they were all for it.
So we built the hospital.
And I'm just saying that that hospital
is the largest solar powered hospital,
probably in the developing world.
But it's also the leading trainer
of Haitian physicians and nurses,
and has been for years now.
And again, this was against
an undercurrent of censorious
opinion from the experts.
And I'm still amazed by it,
I don't talk about it that much.
But my Haitian colleagues were
like, that's what blonde do.
Blonde doesn't really
just mean white people,
it means foreigners.
- I was gonna say, I'm exempt of them.
- No no, You're a blonde.
Definitely.
But you look good.
- I told you it was about the hair,
I need to work on that.
- I'm right behind you.
- You see, there is at least
something I beat you to, right?
(audience laughs)
But sticking with the
topic on global health
and what the medical school
establishment could do.
What do you think a university like Duke,
we have one of the largest
medical schools in the country.
What could we be doing differently?
- Well, I just want to say
there's a lot that is being done right.
The engagement of Duke in global health,
that's for the last 15 years or more,
I think you came here in 2009.
That's already,
and there are people
in this audience you are on the faculty,
there are students,
there are staff who were deeply
involved in global health,
and that really wasn't a health
when I was a student here.
That was 1978 to 82.
And that is,
where there was a great deal of interest
already at the time in the medical school
was already a giant medical school,
huge medical school back then,
the health system was already enormous.
But the interest in global
health wasn't there,
and I'm sure it wasn't at Harvard either,
it wasn't when I went
to medical school there
after that year in Haiti.
So that's one, I just want to say that,
because there's a lot more Duke could do.
But I think my critique
is really of the academic,
of the American University in general.
And it's a delicate thing to make
this critique as a faculty member,
but it's important to do,
and I'm talking about
me as a faculty member.
I think American universities
are so risk adverse
and their focus on risk,
our focus on risk is
really about risk to us.
And I have some news for you,
Harvard is not at great
risk, and neither is Duke.
These are epicenters of resources
that should be shared,
and the risk aversion plays itself out
especially across these national borders.
So just 20 years ago probably,
if you looked,
I really talked about
my first decade in Haiti
as not a wasted decade,
but I don't know that it
was particularly helpful
to the Haitians, which was a criteria.
What's that?
- You learned something.
- I learned something, right,
but again that's a steep,
if the second decade and
third decade didn't follow,
that would be not a great track record.
People are starting to get my humor,
I'm in Page Auditorium.
And I'm just saying there was
a lot of Mickey Mouse activities
that universities get involved
in that they would not tolerate.
You wouldn't have that
at Duke University
Medical Center in Durham,
our at the Brigham Women's Hospital
or at Harvard Medical School.
So addressing that in an
honest but nonthreatening way
is a very difficult thing to do.
So are we moving in a direction
away from silly projects,
and hopefully harmless but silly projects,
but some of them probably harmful.
Are we moving away from
that towards serious,
sustained engagement
in global health equity
with the E on the end?
I think the answer is yes.
But the risk aversion remains a problem,
and another problem is Balkanization,
by the way, I said that once at the UN,
and they said we don't
use that word at the UN.
I said okay, well then silos,
and Anne Becker from
Harvard Medical School
she's a colleague of mine,
she said, and from the
Midwest and I resent that.
(audience laughs)
But you know what I mean,
in Harvard it's even formalized,
every tub on its own bottom.
Like what the hell does that mean?
- You need a pass to go
from one department now,
just between schools.
- Yes, you need a hall pass.
Duke is less constricted in that way.
- It's very proud of that.
- Because Duke the hospitals
and medical school are not separate,
and I think that's an advantage,
and I think that some
people like Victor Zhou,
when he was Chancellor for Health Affairs,
really tried to take advantage
of his experience at Harvard,
he was my boss actually at Harvard
and did a lot for global health,
I can tell you that
when he was chief of
medicine at the Brigham.
But coming here there was just more,
it was not every tub on its own bottom.
And we should resist that.
So Duke could do better,
but it's doing better
than some universities
at resisting that silo
isolation or whatever it is.
That may be an overly
arcane kind of critique,
but I think for people here
who are on the faculty and administration,
they know what I'm talking about,
we have to fight to tear down those walls.
- So you mentioned something that relates
to a point that's been something
that's been on my mind,
which is an health over the
years, over the centuries,
we have done some things
that have been actually not so very good,
there have been some nasty
things that have happened
and that have led to a breakdown of trust.
And so along with several
colleagues of mine
we've been developing this
nascent state of the project,
usually you shouldn't be
talking about nascent ideas
because someone else will steal them,
but in this case--
- Stealing ideas is a good thing.
- It's a good thing, because
then they can do stuff and
I can claim credit for it.
- Yes, excellent.
This is a strategy for tenure.
- There you go.
Wait, what?
- Nothing.
(audience laughs)
- But this idea of trust is crazy,
because what we are seeing now
is there's been an
increasing breakdown in trust
in the healthcare industry as a whole.
So globally on one hand what we have
is a growing amount of
information that patients have.
If you believe Kenneth Aloe's 1963 work,
it said it was supposed
to make things better.
It has made things better,
but it also has meant patients
have now started questioning doctors,
which didn't happen earlier.
And this breakdown of
trust where we see that,
is also in the most unfortunate settings
where you start seeing
violence against doctors.
Is this something you've?
- I've not experienced that,
but I did today with students,
a number of students brought this up
and I was asking not
a rhetorical question,
and these were not medical students,
but I was saying actually some
of them that I met with today
are high school students
who have come here under in
this room I think right now.
Who else can draw high school
students to Page Auditorium?
- Rock stars.
- Yes.
I'm just fabulous.
- [Woman] John Bolton.
- John Bolton, he'll be out in a second.
But you know I was asking
should you be able to graduate
from an American medical school
and not know what the
Tuskegee experiment is,
and I don't think you should.
And I hope no one at
Harvard Medical School
gets their MD without knowing about it.
And learning about it
formally in the curriculum.
But speaking of Ken Aloe,
there is an eminent,
she's an economist but also a physician.
- Are you talking about Marcy?
- Yeah, I am.
I recruited her by the way
from Loyola Medical School to Harvard.
I'm proud of that.
Okay, this woman, Marcy,
she did an MD,
an MPH, I don't hold that against her.
(laughs)
- An MD, an MPH,
she trained in internal medicine,
pediatrics and did a PhD in economics,
which again.
- She's crazy.
- She's crazy,
and then she trained clinically
in infectious disease.
Oh, and she has a family.
Anyway, she went to Sanford,
and I do hold that against
her, but she's back now.
But she just recently presented to us
a study that she's been working on
which is tracing the impact
of the Tuskegee experiment today.
- [Menoush] On trust.
- On trust.
- [Menoush] Lack of trust.
- That to me is the kind,
if we want to understand a lack of trust,
and I'll go back to
the violence against
clinicians and a second,
if we want to understand
the impact of racism
and the historical burden,
and the historical burden of
crimes against humanity here,
then those exactly the
kinds of studies that
we should know the answer to that.
And I think she is working on,
she's already sharing this widely,
and works with many colleagues.
I think that's an
important historical answer
to the contemporary question about trust.
- [Menoush] But it goes
even much further, right?
So Tuskegee goes back,
and it was horrible,
but on a minute level, on a micro level,
if you go to most developing
countries in the world
the patients experience
might not be great,
there is discrimination
based on your social class,
or your caste, your skin color.
And that's bad enough,
that creates that same level
of distrust that we talked about.
And it exaggerates the access to care,
the way people come to the clinic,
the care they receive as well
as how much follow-up there is,
which is essentially a recipe for--
- Can I give an example
from personal experience?
In west Africa with the Ebola epidemic,
how many papers and
commentaries, true by the way,
did we read about the crisis of trust,
and all those things were true,
meaning there was no trust
in the medical system,
but there wasn't a medical system either.
That was a clinical desert.
So you could mistrust
doctors all you want,
but if you never meet one.
- [Menoush] Yeah, there's nothing--
- And I'm saying that's an extreme example
of a setting I've seen many times
where there's no,
if you work in rural areas you see it,
you can see districts
without hospitals at all.
Hospitals without nurses and doctors.
In this example, again, this
is just a personal experience.
One of the things that we did,
I mentioned this earlier.
There were a lot of attacks,
there was an average
of 10 attacks per month
in Guinea on the Red Cross.
That's a lot.
And I can have some
hypotheses to explain it,
but I can just say when we were
in these arid clinical deserts,
where everything was closes,
the hospitals were closed.
In one place in Sierra Leone
something like six out
of seven nurses had died
in the public hospital.
By the way, this is the same district
where diamonds come from.
The blood diamonds.
Koidu district.
Kono district, the capital of it is Koidu.
Everything is shut down.
There is no functioning hospital,
it's a crisis, a lot of people have died,
of Ebola.
A lot of care providers as well.
What would be the way to
address that crisis of trust?
And all I could come up with,
all we could come up with is
why don't we go in and
take care of sick people?
You look at the
coronavirus discussion now,
containment without providing care,
I don't think it works very well.
Give me an example of an epidemic,
I just give you an example
of Ebola where you can say,
we're not concerned with
the quality of care,
we're just concerned with
stopping the epidemic.
To me that's a colonialist
recipe for mistrust,
and it's the one that has held sway
from the late 19th century
on through the 20th.
- But actually there is a brand-new paper
that looks at the controversy
that speaks exactly to
your point and Ebola.
So I do a little bit of
work on accountability
and using community-based
monitoring mechanisms
to improve delivery of care,
and holding healthcare
delivery accountable.
But Andre Duvet, who is at Chicago,
and Joanna Haashofer
at Princeton and others
have this really interesting paper,
talk about being at the right
place at the wrong time,
which is they were doing the study
on accountability in Sierra Leone.
And working with the government
and the World Bank they had managed
to introduce in about 300 communities,
community-based monitoring systems.
And Ebola struck.
So it was really bad.
It was really bad.
- It was horrible.
- It was horrible.
But what we find is in areas
where the accountability
systems were already in place,
with community-based activity
and community-based engagement,
they find large effects in
terms of utilization of care,
and the fact that people,
there is some small mortality fixes there,
but in general,
even though the epidemic
just wiped out everything.
But even then they were able
to see some improvements in utilization,
and how people received care.
- [Paul] I don't know that paper.
- It's not yet been published.
- It doesn't surprise me,
in other words even that
can leave a residue.
- Exactly.
Even in the face of Ebola,
having strong community
mechanisms to engage people
And hold delivery accountable to improve,
hopefully improve trust.
Is very promising in that case.
- I'm a true believer by the way,
meaning in the sense it is,
it can be awfully tedious,
but it's mandatory.
Meaning that exercise
and accountability is just
as good a word as any,
is it seems to me, mandatory.
That's how my colleagues
in Sierra Leone and Liberia proceeded.
- But you mentioned coronavirus
and I do want to talk about it,
but before we get there I want to ask you,
a personal story.
My mother-in-law was getting a
hip replacement here at Duke,
and that she was going through the process
we were trying to figure out
what's the best place for her to go.
And she's deeply distrusting
of the medical system
like many of the people.
And it was really hard
to decide where to go,
because her first question
was which one has better outcomes,
which one is not going
to fleece me on prices,
it turns out these simple questions
in the US healthcare system
are extremely hard for a patient.
So as we think about
building trust in the system,
it's bad enough in Sierra Leone
and India and other parts of the world,
but in the US,
where we like our individual doctors,
but we distrust the system.
How does one think about
building trust in the system
as a doctor you've encountered patients
both in the developing world and here,
how would you think about that?
- I don't think, this is
a look of thoughtfulness.
Now they're finally laughing.
- You need to stay a little longer.
- I don't think of this is
different for the United States
from what I described in Sierra
Leone, or Haiti, or Rwanda.
There's something to be said for,
as an antidote to mistrust,
shutting up and listening to
patients and their families.
And it takes some discipline
to shut up and listen,
you'd think that if you had an
MD and a PhD in anthropology,
two fields where you're
supposed to shut up and listen,
you'd think that I would
be a pro at it, I'm not.
It's hard to do.
And I do think that the
pressures on American clinicians,
when I say clinician, I mean
nurses, physicians, et cetera.
The pressures of a fee-for-service system,
which basically we have
to just acknowledge
our system is rotten in that way.
And that's why for your mother-in-law
there's all this question
about what should this cost,
or cost to the insurance company,
or her, or you, what should it be.
That already I think compromises
trust very significantly.
The fact that I don't
know how to address that,
but I do think we have to say,
the system is in part problematic
because it is a fee-for-service system.
Another is that there's
not a lot of time to sit
and shut up and listen
if you're being clocked,
and you have to type,
clinicians now spend more time
staring at a computer screen,
even when they are sitting next to,
not across from the patient.
- Patient, this is how you do it.
- So whether you look at
the structural issues,
which are really important to do,
historical, the way health
insurance systems work.
The fee-for-service system in general.
And let me say the obvious.
I love working at a fancy
hospital like the Brigham,
we've got everything.
There are dozens and
dozens of operating rooms.
I can't believe what I was just thinking,
which is we have dozens of operating rooms
and I didn't have to build them.
I didn't have to put in a
generator with electricity,
anyway,
I do think every time I
walk into the Brigham,
- It just appears.
- Electricity.
But it's a great place to work,
and there isn't a lot of
pressure on the sub-specialists,
medical professor types.
But you look at the system more broadly,
it's got all of these structural flaws
that make it difficult
to shut up and listen
and provide good service.
Again, I don't feel that is a pat answer,
it's just the kind of
thing that I struggle with
and I'm sure other American clinicians do.
- Which basically tells me that
I'm at least barking up the right tree.
- You are, as usual.
- As usual.
Thank you so much.
- It's true.
- But you mentioned coronavirus.
- I did.
- And there are several
members in the audience--
- They have coronavirus.
- Well--
(audience laughs)
- I'm thinking.
Remember what I said though,
care over control.
I'll take care of you.
- At Brigham.
- Why not?
I'm sorry, I interrupted you.
- My question about coronavirus is,
you know the new JAMA paper
that came out a couple of days ago,
and one of the things
that it talks about is--
- I told you I should have read that.
The JAMA paper.
You know what shocked me about that paper,
which I haven't read yet.
- Tell me?
- It's scary, because if I'm not mistaken
from the abstract.
(audience laughs)
- It's a very short paper actually.
- It's very short, it's JAMA.
My idea of a short paper
is like one of yours,
like 30 pages.
That's like a foot note for me, 30 pages.
If I'm not mistaken,
it says that 26% of
patients in that cohort
required supportive or
critical care, is that right?
One quarter of them.
- Possibly.
- What a warm endorsement.
- I don't know the details.
- I'm in Page Auditorium citing
a paper I haven't read yet.
- To someone who hasn't
read it that carefully.
- You haven't either?
But the troubling thing about it,
and this is why someone
sent it to me this morning.
I mean, I read the New
England Journal of Medicine,
not JAMA.
- [Menoush] JAMA, low-budget.
- But if that's true,
that a quarter of patients in that cohort
required supportive or critical care,
that means hospital care.
- So it's not--
- Think about that,
what if a quarter of people in
a place like Sierra Leone require,
or Liberia?
That's why the Ebola
experience is relevant to this.
- It is, and actually
this is the part about--
- It is, but I can tell.
- No, you mentioned about containment
and I wanted to point out was
the JAMA paper, what it
points to is two things--
- [Woman] Wait, you didn't read it.
- I read enough of it
to have talking points.
That's all you need.
I've been doing this for long enough.
But the point is,
the paper essentially talks about
it has much higher transmission rates,
and it still don't have a clear idea
about how the transmission happens.
But conditional on being transmitted,
the fertility rates are not that high
compared to some of the other diseases
that have been government around,
SARS and MERS and stuff.
So it creates this bizarre thing
where you are worried about
it transmitting a lot,
but the high fatality rates,
or even the complications you mention,
this happens only among the vulnerable,
the elderly populations.
Folks who are 30, 40 years or lesser,
it doesn't really affect
them all that much.
In fact the young kids,
the really young ones in the single digits
don't seem to have a
problem at all with it.
So it's important to think
about what that means.
Because a lot of people
are concerned about travel.
Even just within the
last three or four days
I've been getting on WhatsApp
all these different messages
from folks all over saying,
do you know should be travel.
As if I should know anything at all.
So this is my way of
channeling statistics to you.
- They should have been on a plane.
Impala to Durham via Amsterdam,
then you wouldn't have had that hassle.
Wait, you were.
- I was, London.
- Before we leave the
question of transmission,
it seems that,
and again I'm trying to avoid jargon,
but if you cough or sneeze
and spew respiratory
droplets into the air,
X number of feet away there's
gonna be a decreased risk,
and the closer it is to
the person who is coughing,
the higher the risk is.
That much I think we know.
So it's spread person-to-person.
And it would be great if it weren't,
if the coughing and respiratory
route were not involved.
But I don't know that that is likely.
I mean look at SARS,
another at the time novel coronavirus.
It seems like there was substantial
nosocomial transmission,
meaning inside institutions.
And I'm still worried about
young adults and children.
I just don't think we know yet,
as you would say we don't know
the denominator or the numerator yet,
and I do think it's worrisome.
That if we had a containment approach
without a focus on a quality of care,
and the substantial number
require exactly that care,
then when you get into the clinical desert
in places where there isn't that,
I understand why my colleagues in Rwanda,
Liberia, Malawi, et cetera,
are very anxious about it.
When it comes here, we'll take care,
people will have that kind of care.
We should expect very,
very low fatality rates,
or case fatality rates.
- When it gets here.
- But I don't think that's
gonna be true of universal,
and just a difference between
what's happening inside the city of Wuhan,
or outside in Korea or
somewhere else in Japan.
Just a difference between 4%,
and let's say .5%,
what could that be explained by?
I think it's that equality of care.
- So to your point,
the state of Kerala, my home state,
I always find nice things
to talk about my home state of Kerala.
- Everybody, it's like a cottage industry,
how awesome is Kerala?
- And the food.
So Kerala was the first state
that had coronavirus cases in India,
and there were three students
he was studying in Wuhan and come back.
But the costs Kerala had been
doing exactly what you said,
that is they had been dealing
with the Zika virus in the previous years,
so they had the containment strategy down,
And had reasonably good quality of care,
especially relative to the rest of India.
So they were able to identify
those particular cases who had come in,
and all the contact tracing.
And within days, they didn't even wait
for this to break down
into an epidemic to say,
look we have a problem.
They didn't call it an emergency,
they called it a state disaster.
Because they could then
start various aspects
of the state machinery to
keep the containment solid.
And within a week, I had managed
to keep this under control.
You don't even hear about it any more.
- I did not know that.
But again, this is just a hypothesis,
the quality of care will determine
how much people trust the system.
Back to your original point.
You have shady medical care,
it will have a corrosive effect on trust.
- So I think we are getting close to time
when we need to hand over
questions to the audience.
So we have three mic runners
from the audience who
will be taking questions.
- That sounds like a cool movie.
Mic runner.
- Mic runner, actually
that is, your right.
- We should do that.
I'll star in it.
- Before we turn it over
to audience questions
I have a request that we keep
questions framed as questions,
not--
- Wait, we are in a university,
no one is gonna do that.
- But we have to try, we have to try.
And short questions as much as you can.
- Also impossible.
- I think we have one
question already waiting,
go ahead and please introduce yourself
and tell us who you are before
you jump into the question.
- [Woman] Hi, thank you
so much for your talk,
this was really interesting
and gave a lot of
different food for thought.
So one thing I was wondering about,
picking up on the issue
of structural issues that you mentioned,
so in the context of what the future
of global health equity will look like,
what do you think are some of
the ways that we can move beyond,
you had mentioned of course the first step
it's thinking about the historical honesty
of what has led to some
of these inequities
that contribute to for
example, a culture of mistrust,
specifically in the case of
the Ebola outbreak in West Africa.
So the first step is recognizing
that, acknowledging that,
speaking to that.
What are other ways
that we can move beyond
that, just acknowledging it?
- Well I just want to
say about that assertion
that I have never seen it happen,
historical accountability.
That would be novel,
before we move beyond it.
I still think it would
be a minority view to say
that the Ebola epidemic in West Africa
is related to the wars,
is related to the colonial history.
You could say, what about Liberia,
that wasn't a colony.
Yeah it was, it was an
American settler colony.
So I didn't push that exercise,
if I'm seeing actions in
an Ebola treatment unit
and I start saying,
let me tell you about the history
of the British in Sierra Leone,
that could not be a good
timing for historical lessons,
but I don't think it's been done.
So I do wonder how beyond that,
that would still be an important wish.
Back to the pragmatics though,
is how to we build out,
that's something they say here, build out,
how do we build out health systems?
And it's not rocket science.
Staff, stuff, space, and systems.
I would say you want to
address the recent epidemic,
if it was a clinical
desert before the epidemic,
and just in Sierra Leone
I think it was 211 doctors
and nurses perished of Ebola,
just in those two years.
Including a couple of friends of mine.
So it's worse afterwards,
and there was this big influx.
Modu Pai would have a lot to
say about it, and probably has.
A big influx of assistance, and then boom,
everybody left.
So another thing is,
is that really the best way
to respond to an emergency,
by addressing the
emergency and then leaving.
Disaster relief organizations
seem to believe that,
but I do not.
I think there are lots of resources
that go into disaster
relief organizations.
I told you about our experience in Haiti,
we weren't even a disaster
relief organization
and people sent us unsolicited
donations after the earthquake.
And that happened with Ebola as well,
and those resources, human resources,
capital, they left as
soon as it was seemly.
And it wasn't seemly to the
Sierra Leoneans or Liberians.
I don't speak for Sierra
Leoneans or Liberians of course,
but I'm saying I can
hear what they are saying
when the clinical desert
is as arid as it was.
Hey, Peter.
I just saw one of my professors, sorry.
It does grab you when you see
one of your undergraduate professors.
So I think we really ought to keep,
no matter what it is we are
doing on the pragmatic side,
or the implementation side,
we still ought to try
and keep that historical
process going forward.
It's really being demanded I think,
back to the point of
community accountability,
it's what we hear a lot
of, is what happened,
why did everybody leave,
where did the money go?
Of course they blame their own government,
which is very convenient to
the international players
who did have the capital.
It wasn't the Ministry of Health.
And they are the ones who got blamed.
And I think setting the
historical record correct,
even on this recent score is important.
Anyway, it's not what I do
is to go on and on about
the history of a problem,
but it's important to do as well.
Thank you.
- [Woman] Hi, thank you.
- By the way, when the lights went up
and then I could see my professors faces,
I'm glad they didn't go up.
- [Laura] Hey Paul, Laura Hemingway.
- How are you Laura?
- [Laura] Good, how are you.
From Chapel Hill, but
here I'm here at Duke.
I have so many questions,
it's great to see you again
and welcome back to North Carolina.
But to put myself in the spot
of a lot of students here,
and thinking about the
future of global health,
we've talked a lot,
there was a great conference
here a couple of weeks ago
about the need to
decolonize global health.
So what's the role for students
who are graduating with
degrees in public policy
and public health and
really want to work globally
and want to give back?
It's very different than it
was way back when I did my MPH.
- Yeah, I think it's different,
and in so many ways better.
And certainly by the way, I understand,
and I spoke with some students today
who were asking some
very pragmatic questions,
yeah, but what should we do?
And it's important to be pragmatic,
I think this gets to your point.
If people who are graduating now,
or people who are students now
can move forward the discussion
in an honest manner,
and you've seen this over as I have,
And think about the problematic
nature of global health,
without the E on the end, Equity.
I don't even say public health any more,
I just say global health and equity.
If that's what I mean.
And we never heard that when
we were studying this topic,
and I think we should insist on it,
because the traps of public
health paradigm in general
are significant and real.
In fact in many ways,
they are more treacherous than
being a nurse or a clinician,
is in public health there
are too many Luddites
who are willing to say
there is nothing to be done,
it's not cost-effective, not sustainable.
And I think graduates of programs
today should be suspicious of that logic,
which is really neoliberal
logic under various guises.
And again, not something
I heard as a student,
I was mostly a student
at the medical school
but that doesn't mean I didn't
go to the School of Public Health as well.
And I think embracing that, owning it,
and pushing that agenda of equity forward
within various forms of public
health clinical practice,
the big bureaucracies.
Aid bureaucracies.
And I'll name them,
like USAID, the World Bank.
The largest NGOs,
having those messages
inside those organizations
will be a very welcome development.
And I think that's the
future of global health,
is global health equity.
And that comes with
the younger generation.
That may sound uncharacteristically rosy,
but I mean it.
Thanks Laura, thank you.
- We have a question up top,
and I would request also audience
members who have questions
to please find our mic runners,
we'll keep alternating between them.
So yes?
- [Katie] Good evening,
my name is Katie Grimes,
thank you so much for being here,
and thank you Laura for that question,
it was the perfect segue to mine.
So I'm curious based
off of your experience,
what do you think NGOs should be doing,
or how should NGOs be behaving
in order to better contribute
to global health equity.
Knowing that the way the system is set up
we are so concerned with
reaching our targets
to make sure we receive
funding to continue helping.
Well, having worked in an
NGO for the past 10 years,
or a few NGOs for the past 10 years,
speaking with local
stakeholders there is such
a frustration they don't have
a voice without the system is set up.
So how should NGOs?
- Well you know again, a formula
that would be hard to apply
in the places I've worked,
which are quite varied.
Siberian prison, a rural
squatter settlement in Malawi.
But I think I'd be willing
to go out on a limb
and say something that
I think NGOs could do.
We're sitting in an NGO,
last I checked Duke University
is a non-governmental organization,
and so is Partners in Health.
But you probably weren't
talking about the University,
but I'm talking about
the same thing you are,
the NGOs.
I think if I look at our experience
in Haiti and Rwanda again,
it's over a long time and
many thousands of people.
One thing that you could do in any place
is to support a public sector safety net.
And that sounds so damn nerdy,
but what does that mean?
In the first 10 years,
the ones I was being dismissive of,
my first 10 years in Haiti,
what changed was not me, who cares?
I mean I care, and I hope you do,
I know Laura does.
But what changed was
that we started focusing
all of our energies on strengthening
the public sector in Haiti.
So all those hospitals
from the Dominican border
to the West Coast that Partners
in Health sister organization
are involved with,
they are all public facilities.
And that would be a big
shift for most NGOs,
who as you point out concerned
with their own metrics
and their own donors.
But I can just say Partners in Health
would not be a large organization
without having made that shift.
And we wouldn't have been
invited into Rwanda anywhere.
Which was we were invited
there specifically to do that.
And I'm not saying it's
the only thing to do.
But let's say you're a missionary group,
there is no law, at least
none that God handed down,
she speaks to me personally.
There's no law that says
a missionary group can't
support the public sector.
There's no law that says a
non-governmental organization
can't support a public
school or a public clinic.
And again, I think it
would rattle a lot of NGOs,
but probably not as much as you'd think.
It's a way to reach a lot
more people certainly.
And again, that's not a formula,
because it's different to be
in Siberia in the late 90s
and Siberia in the late 80s.
It's different to be in
Siberia than in rural Malawi.
But in both of those instances,
I've seen the power of working
with those responsible
for the public well-being,
and that's the public sector.
And now this from someone
who's never worked.
I've never even worked
for Partners in Health,
but I certainly don't
work for a government.
My day job is at Harvard, right?
But that doesn't mean I
can't look to our colleagues
in ministries of health and say, hey,
how can we be useful to you?
And again, it might not be
by doing work only in a public hospital,
of course not, I wouldn't
be so prescriptive.
But saying that to your
beleaguered colleagues
in a Ministry of Health, hey,
how can we be useful to you.
I think more and more NGOs should do that.
And, I know this is longer than you want,
but I tried to say that quite
a bit after the earthquake in Haiti.
And I didn't get a lot of applause.
I think my Haitian colleagues were happy,
but saying that directly to
the larger NGOs and contractors
was a personally unpleasant
experience for me.
Because I got shouted down.
I was like, you ask my
opinion, then I shared it.
But it was not a pleasant experience
taking on the larger NGOs.
Just saying hey, I think we should do
more to help the Ministry
of Health in Haiti.
It was not fun.
- I think we have time
for one more question.
- I have time for a thousand more.
I flew here for this, and so did you.
- So did I, maybe we
should just stay on for?
- I think, yeah.
- No, we are both on a tight leash here.
- John hasn't come in yet
to sing, but any second now.
Come on, I'm hilarious.
- [Angela] My name is Angela
Gillham, and I'm a Haiti hand,
I grew up there.
And I run a small organization
near the Dominican border,
we serve about 65,000 and
there is no public option,
we are the only healthcare.
- I very much admire your work by the way,
and it's an example of if there isn't that
public option, thank God there are people
holding the line clinically.
- [Angela] We are trying to facilitate it,
we provide primary care,
and then of course we get
people to Mirebalais sometimes.
But my question is
specifically on cholera,
which we went through
in our region last year.
And I was involved with UN,
and at the national level
with the Minister of Health.
And the UN, they brought
the cholera to Haiti,
they were very quick
to say in one meeting,
well, there's not been any
for 30 days, so it's gone.
And we know that to be not true,
and we know from our region
when we let the Minister of Health
know that we had a case,
they came up and brought us Clorox.
Luckily we were a little bit
better prepared than that.
But what can we do?
Is there a appetite?
I live in Chapel Hill, a UNC grad.
But what can we do as an
academic community here in the US
with these great resources
and these great minds
to come in after Ebola,
two come in after cholera,
when maybe the UN and
the Haitian government
is probably not that
happy to talk about it.
How can we come in after
these huge disasters,
which don't have to be a disaster,
but we could come in with
programs involving students,
it would be a really amazing opportunity,
but there just doesn't seem to be a will
to have project based for
instance, cholera in Haiti,
or Ebola where it's something
where we could say as a community
that we care enough to come
in and stay for 10 years
and really make sure that it's gone,
and I would love to hear your thoughts
on pulling that support together,
because that's one of
the goals of Serve Haiti,
which is my organization.
- Well first of all I
think all of these things
that we are talking about
or 10 or 20 year projects.
You have to admit, were
you surprised that I said,
my first decade, a waste for them.
But I wasn't just being light,
I was trying to say how
much did that add up to.
As you pointed out, rather
archly, well you learn something.
These are all long-term projects.
I think Judith was impressed
by this term I used earlier
of pragmatic solidarity.
And again, I probably got
that from the Haitians.
Solidarity is not a short
term project based affair.
It's something that is cultivated
over one would hope decades
of life times, et cetera.
The pragmatic part is difficult,
because there are so many Haitians
who would like to be
involved in these projects.
And one of the things that I've seen,
and I hope by the way
the people you referred
were happy with their
experience in Mirebalais.
The biggest problem is that
there are 2000 people a day
that my colleagues see there.
It's become a de facto referral hospital,
as you know for the country.
We get people from Boston,
Haitian Americans from the diaspora
who come from there as well.
The reason I bring up Mirebalais again,
is really because it's
all run by Haitians.
So what is the lesson there?
I think if you take on a
project, a problem like cholera
all the way to eradication,
it's going to necessarily
involve the agency
of local communities like
the one you're working with.
And some of the things
I just didn't listen to
in those first 10 years,
I didn't think hard enough
about how to retain people
through respect and decent jobs.
I also don't think,
again, I don't mean to personalize this,
but you asked me,
I don't think I listened
and often people saying
I would like the same kind of training,
formal training.
And this was true of
community health workers
talking about credentialing,
and this was true of young people wanting
to be nurses or physicians.
And again, that was
another chance to say okay,
what can an NGO do to offer
basically a university.
And as you know in Rwanda,
we ended up building one.
And don't think we wouldn't like
to build the same thing in Haiti.
Think of all those people
you must be seeing,
young people who say I
really want to go to,
and then they'll name a university,
or it'll be in the DR,
it'll be the United States.
And I know that for me I was trying
to not hear that for a long time.
And I know that may seem a
long way from a smallish group
with a smallish catchment area,
but I think it's not.
And I think again,
listening to those entreaties or whatever
and finding ways to involve young people
who want that kind of training
in a specific endeavor,
like cholera eradication.
At least that's being what
I've seen in central Haiti,
is even cholera eradication
should have room for formal,
again, training seems
such a strange world,
but for formal engagement
over a long time.
And I think NGOs back
to the questionnaire,
I think NGOs can do that.
You have this connection with Chapel Hill,
with Duke.
That's a University,
this is a research triangle.
How do we match our capacities here
with the aspirations there.
And I don't mean to be too
philosophical about it,
I'm just saying that we tried to do
with resources in Boston
is how can we bring.
And just one little example,
on the vaccine, the
cholera vaccine research,
I don't know how you'd get
rid of cholera entirely
without using every tool
at your disposal, including vaccines.
That work was again,
done with local Haitians,
including researchers,
implementers, et cetera.
But it was the first time
that vaccine had been used,
and it was studied and documented.
That's the work of a university town
or a place like Chapel Hill or Duke.
And I think again, it's a tiresome answer
to a specific question,
but it's been my experience
that we just don't push hard enough.
If there were a cholera wreck
in Durham or Chapel Hill,
there would be a fire alarm.
What's that?
- [Woman] No one would die.
- No one would die,
and there would be lots of
new knowledge generated.
We should be doing that in responding
to these problems as well.
- Excellent.
So I think we are at time,
so let's thank our speaker today.
Paul, thank you so much for coming.
- Thank you.
(audience applauds)
- That was wonderful.
- Thank you.
