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March 10, 2022 29 mins

Dr. Paul Farmer, who passed away unexpectedly in Rwanda on February 21st, fundamentally changed the way healthcare is delivered in the most impoverished places on Earth, touched millions of lives, and inspired countless others to follow his example.

In tribute to his extraordinary life and pioneering work, this special episode features a conversation between Chelsea Clinton and Dr. Farmer from 2019, as well as President Clinton’s reflections about his longtime friend.

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Speaker 1 (00:01):
On February, the world lost one of the most extraordinary
people I've ever known, Dr Paul Farmer. As co founder
of the global health and social justice organization Partners and Health,
Paul fundamentally changed the way health care is delivered in
many of the most impoverished places on Earth. Along the way,
his fine mind, big heart, and relentless and fectious strive

(00:24):
to do good and have a good time doing it
inspired countless others to follow his example. My family is
profoundly grateful to have benefited from Paul's many gifts for years,
going back to the time Chelsea read his work at Stanford,
reached out to him and gained his mentorship and friendship.

(00:45):
I'm honored to have worked closely with him in Rwanda
to the Clinton Health Access Initiative, which he served on
the board of, and in Haiti, first in bringing treatment
to HIV patients, and then after the earthquake when we
led the U N Office of Special Envoy for Haiti

(01:06):
for twenty years. I watched him make everything he touched
better with his hard headed evaluation of every problem and
his ardent conviction that even in the poorest places, even
in the face of dysfunctional politics and violence, he could
still make a difference. He also managed to become a
wonderful husband, father, son, brother, colleague, mentor, and friend. His

(01:30):
constant kindness to and support for Chelsea as she built
her own career in public health is just one of
hundreds of examples of that friendship. There's a tribute to
our friend. We are re releasing this episode from the
original run of Why Am I Telling You This? Featuring
Chelsea and Paul and conversation. It should give you a

(01:52):
good sense of who Paul Farmer was and what he
was all about, and I hope inspire you to want
to make the kind of difference in the world that
he did. Hi, I'm Chelsea Clinton. Welcome to Why Am
I Telling You This? The Clinton Foundation Podcast. In many ways,

(02:16):
our world has never been healthier Globally, people are living
longer lives and child mortality rates are down, but one
million children still die in their first day of life
and one million more in their first month. We know good,
equitable primary healthcare, and adequate disaster preparedness and response would
help save newborn, child and adult lives. My guest today,

(02:38):
Paul Farmer, has spent his career trying to build health
systems that can do just that. He is a singular
and inspiring figure in the field of public health. Paul
is one of the most remarkable individuals I've ever known.
Through his tireless advocacy and work with an organization he founded,
Partners in Health, He's transformed health systems in some of
the poorest places on Earth. Seven Ophelia Doll, Paul Farmer

(03:02):
and fellow Harvard Med student Jim Kim established Partners in Health.
They had no funds but high ambitions to bring healthcare
to the kneed. Paul Farmer has worked tirelessly to treat
individuals while spreading the medical gospel of healthcare for all.
For the first time, patients in a public hospital are
able to receive chemotherapy. For now, the expensive drugs are

(03:23):
paid for by Partners in Health. Throughout his career, Paul's
worked to build basic health infrastructure around the world. I
came to know him twenty years ago when I was
a student at Stanford, and he's been a friend and
mentor to me ever since. I've had the privilege of
working closely with Paul and Partners in Health in Haiti,
Rwanda and other places around the world. Through their partnerships

(03:43):
with the Clinton Foundation. In each of our projects together,
Paul has brought extraordinary scientific expertise, a commitment to working
with local communities towards their specific goals, and a relentless
focus on making good policies and seeing them through to implementation.
Paul's a lifelong teacher who has been outspoken in his
belief that everyone has an obligation to help narrow and

(04:05):
eventually erase the health divide between the world's rich and poor.
Why am I telling you this Because at a time
when global health crises and health systems are competing for
headlines and an increasingly crowded breaking news cycle, it is
more important than ever that we continue to pay attention
to these urgent issues. Because efficient and equitable health systems
not only save lives, they also break the link between

(04:27):
sickness and poverty that keeps billions of people at risk
across the world. And because we know that while the
world continues to face multiple health challenges, we know that
many of those are solvable in part because of what
Paul and Partners and Health have proven over time. So
thank you Paul for being here today. I want to
start a little bit at the beginning, just as a

(04:51):
starting point to explain why you started partners and health
before we even had the kind of words global health equity,
because that's really what you were doing more than thirty
years ago. Of course, I didn't know those three words
and how to string them together back then, you know,
as an undergraduate at Duke. I mean the first time

(05:14):
I thought maybe I don't want to be a biochemistry major,
which which I was and enjoyed, was in a class
called medical Anthropology. And I only took it because I
had the M word in it, and it was the
kind of course where you were expected to do a
research paper, which sounded cool to me. And uh, you know,

(05:35):
I did mind in the emergency room at Duke University,
I was focusing this question on race and class and
insurance status. So I learned a lot because here was this,
you know, big medical center and African Americans without insurance,
we're using it as a primary care delivery system because

(05:55):
they didn't have another choice. And the history of Jim
Crow and the segregation of hospitals and emergency rooms even
in night lay heavily or perhaps you would say lies
heavily on our country. And you know, here's people coming
in who don't have an emergency, and they're coming into

(06:15):
a university medical center emergency room. Why because the safety
net would not otherwise catch them. Maybe it was that
preparation in the United States, which of course I knew
to be a land of bounty, and I actually not
equally exactly distributed. So I had that understanding, or at
least the awareness that inequalities were local and global. I

(06:41):
had that early on. And even though a lot of
my interpretations proved to be incorrect, a lot of my
understandings were just wrong, ideas were flat out ridiculous, the
basic conviction that you know, people ought to have some
kind of safety net, that that proved correct. And uh,
it's been a tortuous path since then, but uh, that

(07:05):
that's what led you to partners and Health certainly, and Paul,
even though you may not have had kind of the
words global health equity, and you just talk a little
bit about how Partners in Health took the form it
did and why you focused so much on not only
kind of the delivery of care, but also the training
of health workers and ensuring that Haitians were always at

(07:29):
the center of what was being conceived done, evaluated. Some
of this is such a given for us um for example,
that Haitians would be at the center of an endeavor
to promote what we would later call global health equity,
and yet that's not the way much of the world happened.
I mean, it's one of the priorities that's always been

(07:50):
so crucially shared and important to us as people. But
also between all that we've done the Clinton Foundation and
the Clinton Health Access Initiative, and clearly that you've done
and and helped pioneer through partners and health, and yet
even though that seems so obvious to us, it still
remains not the expectation of global ngeos around the world.

(08:13):
And I of course I'm not allowed to forget that
because we bump into many and try to work with
many as well who don't have that as their central
guiding principle. But global health equity is always going to
be a way that can steer us towards that. Universality
has to be about quality, dignity, respect these more ineffable

(08:35):
but still measurable ways of looking at how well we
do thinking about equity. And that's another reason to get
back to your point, to think very hard about making
sure we allow our partners, let's say their rural Haitians
or urban Hattions or whatever, to be involved in the

(08:56):
work as agents of change. And that requires thinking about, uh, well,
who gets to go to a university, who gets to
go to nursing school, who gets to go to do
a PhD in health policy, whatever it may be, who
gets to be an elected official? List goes on and on.
If you want to attack poverty, then you better make
sure people living in poverty at the center of it.

(09:17):
That was clear from that first year, although much was
not the understanding that people need to be the agents
whenever possible of their own liberation from these shackles. I
got that in year one. We'll be right back what

(09:44):
started at is largely providing basic medical care and then
developed into providing slightly more sophisticated medical care with medicines
that you and Jim and others would bring in your
suitcases from Boston to prem Um. Well, you know, certainly

(10:04):
better than nothing. And yet today there are incredibly sophisticated
procurement plans, logistics infrastructure underneath all of what Partners in
Health does, and you're delivering tertiary care. I mean you're
you're able to treat people in Haiti as well as

(10:25):
you're able to treat people in Boston. Can you just
talk about the journey from nine three to now? I
would I would love to. In those early years, of course,
we were we were full. I think we're full of
passion and enthusiasm, and we have just as much or
more now. But some of the things I would later
learn in working with the Foundation, for example, we're not

(10:48):
at all clear. And one of them is what's the
big picture of how the work should look. There was
already a lot of aid money, but the impact of
that aid, say from the United States and UM was
was pretty negligible. If you were showing up in central Haiti,
I could see that UM it didn't have to go

(11:11):
to the squatters settlement of cons just being mere ballet,
which was, you know, on papers, supposed to be a
place where very substantial amounts of USA we're going there.
But there was little in the way of either a primary,
secondary tertiary system. You know, so if you had obstructed
labor and UH you go to a hospital that has
no blood bank and no obstrition and no operating theater,

(11:34):
it's not really hospital. It's not really hospital. It's just
not a hospital. And again I could I could see
that at the time, we could say, is there a
way for us to assess the main problems here? And
this first team that we had to say, let's go
to every household, ask people what's going on there um,

(11:55):
meaning find out who has access to family planning, which
kids have been back stating, how many people live in
the household, try to get it. We weren't trying to
do an epidemiological study. We were just trying to say,
what were the ranking problems here? Could we find out?
And then the community health workers were called c h
vs community health volunteers, you know, and it's hard to

(12:16):
be a volunteer if you've got six kids and other
things to do, Like we're not being paid for your work. Again,
the dignity conferred by work really was it was it
was obvious even to a three year old. That meant
that as we were working with Haitians as our m
o UM, including young patians our age, bad things would

(12:38):
happen to some of them. The initial team based in Conje,
there were six Patians our Age UM and by the
time I graduated from medical school, three had died. I mean,
I had never had friends who died, even though I
came from a family without a lot of means, I

(13:00):
didn't know anybody who died. But these these were my friends,
and they were my age, and it was the first
time in one after another, I was totally grief stricken
when the first of them, the first of them died.
You know, she was twenty seven. I was probably about
the same age. Uh, and she died just after childbirth.

(13:24):
And then right after that, um, another young man. You
know we mentioned water. What's the cost of not having
clean water supply? Well, for babies, gastranoriotis, but for a healthy,
robust young guy, watch for typhoid. And one of the

(13:45):
complications is it bores right through your intestines. And you
know what. I would later become an infectious disease doctor.
But she didn't need to be an infectiousities doctor to think, Wow,
not only is that an outrageous tragedy, it's a good friend.
These are things, by the way, that not only would

(14:07):
have been prevented by having a tertiary hospital, that is,
the illnesses would not have led to death. So you
have a baby, you get an infection, if you have
a good hospital. You're not going to die from it. Right,
you have typhoid, you're not going to have you know,
a perforated bowel, because you get antibiotics and if you

(14:30):
needed to, you'd go to the operating room. He actually
died right outside the operating room. But this is an
important prince and he was so frightened, and I I was,
I had what I was going back to medical school.
I wasn't a doctor. I was just with him and like,
oh my god, he couldn't die, could he? Well, I
knew he could die in it. He's not going to die.
He did, And and then the other young woman had

(14:53):
cerebral malaria. And I'm not the only one who knew them. Well.
I may have known them the best of the founders,
but if you had don knew them all and of
course our Haitian colleagues, and was just devastating, especially knowing that, yeah,
the illnesses should have been prevented, but after someone gets sick,
you can also prevent death, right, you need That's why
you need a medical care delivery system. There's no vaccine

(15:18):
for malaria yet. The vaccine for typhoid is not very good, right,
And there's no vaccine for um, you know this, this
infection after childbirth, except for family planning. Right, So on
every one of those levels prevention and care, we failed, right,

(15:40):
we failed our friends, you know, just say that. It
made me feel bad or guilty, it did, But it
also was my first real experience with grief, and the
stakes were already cleared to us, and we already thought
of this as a health equity issue. So to get
from there again the first decade being mostly errors and

(16:00):
mostly and full of these kinds of tragedies, um, but
but not without joy and and again these friendships. But
it took a long time for us to admit, and
I'm the us here being our Haitian colleagues as well,
that the work we were doing wasn't really very good.
It couldn't be good because it wasn't building up the

(16:21):
Haitian health care system. It wasn't providing comprehensive care. And uh,
we came by that knowledge the hard way. And wherever
there's a clinical desert, right, that is, you don't have
the staff you need and the stuff you need in
the space you need, and the systems and four s.

(16:43):
You know, this global health equity. One reason we keep
going back to that list staff, stuff, space, systems is
because you know, are there guiding principles that could lead
us forward in varied settings? And the answer I think
is yes, I think you've proven the answer is yeah.
You should be seeing all of them. You should be
seeing staff, and it would be local staff, nurses, doctors, managers,

(17:07):
community health workers, everyone who you would need to actually
deliver caring. So the stuff I'm talking about medical supplies, medications.
You know, you have preventives, vaccines, you have diagnostics. How
do you know if someone has HIV? What's ther viral load?
How do you know someone has leukemia? A lab that
can diagnose and identify the cancer? So staff stuff space,

(17:31):
then it should be dignified space. You know, nobody wants
to go to the hospital have a baby when it's dirty.
In addition to all the user fees and other obstacles
for geographic ones whenever, uh if it, if it's dirty
and smells bad, who would want to go there for anything?
So that dignified space is important. And then the systems,

(17:54):
you know, I'll just say it, I learned that. I
keep learning about that, and I'm not done learning about
any of them. But you know, not having a healthcare
system a safety net. Well, that's what I saw as
an undergraduate when African Americans in Durham County We're going
to a giant university medical center for a basic primary

(18:16):
care problem. So the safety net is composed of staff, stuff, space,
and systems. But it's only a safety net if if
it catches you, if you fall. More after this, you

(18:39):
and I spend so much time thinking about kind of
what can we try to improve support empower kind of
through medical care and also kind of more robust public
health systems, And yet so much of what determines whether
or not people are healthy happens even beyond those kind

(19:02):
of large categories. You, how do you think about any
of us who care so intensely about improving health outcomes
and health equity. What do you think our responsibility is
to not just be informed, but but try to be
thoughtfully engaged in these these larger debates of social and
civic determinants of health. The first discussion of social determinants

(19:24):
ought to be well, there are social determinants. You can
work really hard inside the walls of a clinic, or
on drug pricing, or working with the ministry on the
care delivery system, and you're not getting at the major
determinants of who lives who dies. How inequalities getting the body.

(19:46):
Those inequalities can be around raised class, gender, and are
by the way, but also rurality where you know what
zip code you're born in. Um, that that's uh our
daily bread. Right. One of the anxiety at ease that
I have UM is there is a strain inside public
health which is a lud eyed strain. And I've seen it.

(20:12):
We've both seen it again and again where someone said, well,
if poverty is the chief determinant of health outcomes, that
maybe we should focus all of our attention on poverty
reduction and worry less about let's say trauma care. Well,
that would not have been a good thing for me
in when I walked in front of a car, right,
Or well, you should really focus all your attention on prevention. Well,

(20:35):
how do you prevent breast cancer or leukemia? I don't know.
I mentioned getting hit by a car, and I you know,
I couldn't walk on assistant for six months after that.
But I knew that the emergency medical technicians were not
going to lean over me and say you should have
looked both ways. Before you cross the street. Sorry, you know, Uh,

(20:56):
that's what it is for a lot of people who
don't have that safety net, and there are no tertiary
care hospitals. You know, I would hate to have the
world suddenly literate in social determinants and forget about equity
and care delivery. And we've seen it again and again, UM,
And you know, I think there's got to be a

(21:16):
way for us to keep global health equity front and center,
because that would allow us, after all, to acknowledge the
quality of care matters, geographic distribution matters, access matters, and
you have to have that safety net. In the thirty
five years, more than thirty five years now since partners
in Health UM was started, UM, can you talk about

(21:40):
how the works evolved. I wish we were moving faster UM,
but it's so encouraging if you just stick with this
for I was gonna I was about to say, if
you just stick with this for a few decades, and
you know, it's not a long time. I mean what
we've seen in Rwanda to go from the bottom the

(22:00):
pits hell, which endured even after the genocide, because even
when there was federal leadership, still doesn't mean you have staff, stuff,
space and systems. But to go there and to see
what it's like now, I mean, this is not a
long time, just the what we have seen with our
own eyes. Think about Putaro, you know, a place like Putaro,

(22:23):
the district of Berrera, the last one without a district hospital.
First of all, you'll remember those first visits. I mean
beautiful mountains. The wandest most modern hospital was built in
Guitaro in the mountainous north, mostly with funds from partners
in health. This big hospital on top of this hill

(22:45):
mountain is related to a series of health centers and
two people working in the villages. This is a district
of over four hundred thousand souls um and in two
thousand three, two thousand before, there was not a single doctor,
much less a district hospital. They take time to understand

(23:05):
the whole context of their patients lives and then they
design services that will help make their lives better. That
critical insight, that commitment to humanity, is what drives Paul's work.
You know, some people are there startled, Some of the
Rwandans are startled. I've had Rwandans come here and say,

(23:26):
is this a resort, is it a hotel? For mazungos,
you know, is it for foreigners? And uh, and be
skeptical when when we respond, now, this is this is
for you, this is your community hospital, your district hospital.
As a result, the number of children dying before age
five has dropped to a quarter of what it was
in the year two thousand. The number of mothers who

(23:48):
die in childbirth is down sixty six since ninety nine,
in part because nine of pregnant women receive at least
one pre natal care visit. You know, people say, well,
how do you do this work around people are so
ill and suffering, and why isn't that depressing? I can't
think of any less depressing than being able to see

(24:08):
that kind of progress in so short a time. I do, though,
I kind of want to end with asking you not
if you're optimistic, because I know you are, but why
you're optimistic and what are you most optimistic about? Because
while we have seen such tremendous progress, you know, a
massive decline and under five mortality over the last twenty

(24:30):
five years, um, we still have a million children who
die on their first day of life and a million
more who die in their first month of life. And
we still have millions of kids who die every year
from things that are not only preventable um if they
were to be fully vaccinated, but also preventable if they

(24:50):
you knew how to swim, or if there were good roads,
or if there were seatbelts. And yet I know that
you are optimists. So why are you optimistic? And wh
do you think anyone should be when we think about
um global health equity. There's a lot of really wonderful
people who we meet who are drawn to global health equity,
and that's a cause for optimism. Yeah, there are setbacks.

(25:13):
I mean, we didn't even talk about the earth quick.
That was, you know, a dreadful experience um and and
that's probably why you didn't bring it up. I still
don't like talking about it when I see all the
people who kind of involved. Your mother told me that
more than half of all American households contributed two earthquake

(25:36):
relief in Haiti. And to know that that many people
cared about the distant stranger suffering they wouldn't see directly.
That's not even kind of the people showed up. How
could you not say, well, we're redeemable as a species. Yet,
but one of the things that you know, I'd like
to get out, you know, in this exchange is just

(25:57):
as a way of encouraging others. If you get involved
in it and you stick with it, wherever the it,
wherever the it is, who you're going to see massive progress.
Sometimes it's really dramatic and vast. And I would say
Rwanda is the best example. We know what's happened there
in the last fifteen years in terms of just looking
at the basic measures infant mortality, tied mortality, maternal or

(26:22):
around AIDS, spriculous malay or whatever. Those are the steepest
declines in mortality ever documented in history, in history. And
to know that that could happen there, how could you
not be optimistic? You know, I think we are maybe
getting that message out more. But this pessimistic view of
the world is wrong, and of course cynicism is wrong.
Cynicism is is a dead end and that nothing can do,

(26:45):
nothing can ever change, and that's just ridiculous. But I
think that our optimism is warranted. I love and Paul,
thank you. You make me optimistic every day and I'm
so grateful for you in the world and for your
time for our conversation today. So thank you. Very much.
I hope I'm allowed to come back and got a
lot of podcasts in me, even though this is only

(27:07):
my second Anytime, Paul, Anytime? Why am I telling you? This?
Is a production of our Heart Radio, the Clinton Foundation
and at Will Medium. Our executive producers are Craig Menascian
and Will Monnadi. Our production team includes Jamison Katsufas, Tom Galton,
Sara Harowitz, and Jake Young, with production support from Liz

(27:29):
Raftree and Josh Farnham. Original music by Wat White. Special
thanks to John Sykes, John Davidson on hell Orina, Corey Ganstley,
Kevin Thuram, Oscar Flores, and all our dedicated staff and
partners at the Clinton Foundation. Hi, this is Bill Clinton.

(27:51):
I hope you're enjoying. Why am I telling you this?
I started the Clinton Foundation on the belief that everyone
deserves a chance to succeed, Everyone has a responsibility to act,
and we all do better when we work together. In
the more than twenty years since the Foundation first opened
its doors in Harlem, we've brought people together across traditional

(28:12):
divides to address some of the most complex and pressing
challenges of our time. The need for cooperation has never
been more urgent than it is now. The COVID nineteen
pandemic has ripped the cover off long standing and equities
and vulnerabilities across our global community and here at home.
The existential threat of climate change grows every day and

(28:34):
all around the world, the forces of division are tugging
at the fabric of our common humanity. That's why this
year we're relaunching the Clinton Global Initiatives Annual Meeting in
New York in September, bringing together heads of state and
other government officials, leaders of NGOs and philanthropic organizations, prominent

(28:54):
voices and business, labor and finance and youth leaders, and
grassroots activists and drive progress on inclusive economic growth and recovery,
climate resilience, and health equity. While the challenges we face
our steep, our work has always been about what we
can do, not what we can't do, and by bringing
diverse partners together to take action and achieve real results,

(29:18):
we can create a culture of possibility in a world
hungary for hope. I hope you will take a moment
to share your thoughts and ideas with us and learn
more about our work by visiting www dot Clinton Foundation
dot org. Slash Podcast, thank you,
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