Q&A: Dr. Paul Farmer and Ophelia Dahl on recovery efforts in Haiti
Dr. Paul Farmer, U.N. deputy special envoy to Haiti, and Ophelia Dahl, who founded the nonprofit Partners in Health with him in Boston in 1987, are in Los Angeles this week to attend Saturday's “Haiti Stories” conference at UCLA’s Fowler Museum that runs from 1 to 6 p.m. and is free to the public.
Farmer, a Harvard medical professor whose work was chronicled in Tracy Kidder’s bestselling “Mountains Beyond Mountains,” and Dahl sat down Friday to talk to Los Angeles Times staff writer Molly Hennessy-Fiske about their work in earthquake- and disease-ravaged Haiti.
Farmer and Dahl spoke at the home of Dahl’s sister, Lucy Dahl, in Larchmont, which is decorated with photographs and other mementos from their parents, children’s author Roald Dahl and actress Patricia Neal.
Q: What do you feel the biggest public health challenges in Haiti are now, a year out from the earthquake?
Farmer: The biggest public health challenge is rebuilding health systems. In other words, if you look at cholera or maternal mortality or tuberculosis in Haiti, they’re major problems in Haiti, but the biggest problem is rebuilding systems. What I mean is going from community-based care to health centers to hospitals, putting in place a robust system. The second is how to coordinate all the different actors. There’s so many [nongovernmental organizations], there are different hospitals, there’s the health ministry, there are private providers -- it’s a very chaotic delivery situation.
Q: But wasn’t it that way before the earthquake?
Farmer: Yes. After the earthquake, some of the problems of -- I’m going to just call it healthcare delivery -- were exposed to a broader audience. ... The chronic problems that you’ve known about before -- weak health systems, not enough investment in primary healthcare or specialty care, and now, on top of that, this acute problem of the earthquake.
Dahl: I would just add something that’s often not thought of as a medical problem but a lack of support for public infrastructure, so no municipal water systems, that sort of thing -- the cholera being a direct result of that. Haiti’s place of 147 out of 147 countries for water quality, on that index [in 2002].
Farmer: And while we’re listing problems, can I just say the destruction of the urban health education infrastructure, I would put that up there, No. 3 -- the nursing schools and medical schools. We’re a health-focused group, so we’re acutely aware of that. That’s why we have invested so much time and energy in the Mirebalais hospital project. We’re hoping not just to provide good secondary and tertiary medical care that will complement the community-based care we have been working on for 20 years, we’re also hoping to help spark a renaissance of better training programs too.
Q: Why did you choose that area, that hospital?
Farmer: We’ve been working in that area for 20 years. In fact, we met in that city 28 years ago, by my count. So we’ve been wanting to work there for a long time, and have been in recent years in that town. It’s one of the two largest cities in central Haiti. It deserves a good district hospital, community hospital. So why did we grow it into this big project? Because the ministry of health, the public health sector, asked us to be more ambitious after the earthquake and to try to reimagine this project, not only responding to the needs of central Haiti but also the training needs of the next generation. Haiti is always talking about decentralization and nothing has been so obvious, perhaps a weakness, as the centralized nature of Haitian society as being revealed by the earthquake. I mean, they lost all these medical training programs because they didn’t have them anywhere else.
Q: You mean anywhere else outside Port Au Prince?
Q: Can we trust the ministry of health to be doing these things, how much of this should be done by outside NGOs?
Dahl: You cannot afford not to trust that system. We’ve now been working with them for more than a decade and had tremendous success in doing so. We’ve worked in different countries with different kinds of governments and in Haiti, with every imaginable type of government, but our favorite type is the democratically-elected type.
Farmer: You can’t have public health without a public health system. We just don’t want to be part of a mindless competition for resources. We want to build back capacity in the system.
Dahl: For us to build a separate parallel health system is not doing anything to forward the rights of the Haitian people. Much better to beef up the public health system than to build a separate one.
Q: Could you talk a little bit about the cholera epidemic in Haiti and what treatment you would recommend?
Farmer: There’s been a lot of bogus discussion about this. You can spend half your resources telling people to wash their hands or drink clean water, but if they don’t have access to clean water, it’s a peculiarly noxious way of approaching the problem because you’re basically taking a social problem -- which is lack of access to potable water or municipal water supplies -- and making it a cognitive or psychological problem. It’s a terrible kind of irony. ...
The treatment for cholera is rehydration and in our view should include antibiotic treatment because it shortens the shedding of the organism. So it has benefits to the patients in the views of many but it also makes them less infectious over less time. That’s not something that’s about adherence. That’s something we learned 20 years ago -- it’s about access. You put the medicines in the patient’s mouths. You get compliant.
Can we rebuild municipal water systems in short order to save the lives we need? No. We can’t. So we have to focus on point-of-use water purification, which includes filtration for this pathogen. ...
And then, of course, there’s the question of prevention beyond access to clean water for washing and drinking, and that’s access to vaccine. And I think it’s unfortunate there’s been a debate about that.
Q: Could you explain what your point of view is on the cholera vaccine?
Farmer: We should move quickly to make greater investments, not only through cleaning up water but through creating vaccine. The arguments against that, which I think are fading away, is that it’s too hard to manufacture. It seems to me in the last couple of weeks, that debate has moved forward.
Dahl: It was much harder to do that with HIV, to make sure daily doses of antiretroviral therapy was available -- there were so many barrier-laden arguments put forward.
Q: Where should the vaccine be focused now -- in the tent camps in Port Au Prince or the rural villages?
Farmer: There’s a little more water security in the tent camps, ironically. They’re just bringing in water. In a rural village, there’s even less water security than in one of these camps.
Dahl: On top of that, the rural villages that were a little more sparse have now received hundreds of thousands more people. Where once you had eight people living in a house, you now have 15 people in the same two-room hut without access to clean water.
Farmer: One of the things we’ve been talking about in terms of if we were to prioritize those doses is to put some into a rural setting and some into an urban setting and track the impact that has. That’s one of the suggestions being discussed this week -- not a trial in the classic sense, but a division of labor between groups that work in the rural areas like us and others. But it would be nice to get rolling.
I noticed some aid workers or diplomats from Europe and elsewhere, as soon as this started happening, they started getting cholera vaccines.
Q: Are there other diseases in Haiti that people should pay attention to?
Farmer: HIV seems to be under some control. There have been some victories in Haiti. Over the last 15 years it has been halved.
Q: Was all the money donated after the earthquake put to good use?
Farmer: The $2 billion that came in after the earthquake, almost none of it went to the public sector. That was earthquake relief, not reconstruction. The relief monies were used in a pretty good manner. I don’t think people need to feel bad about the relief -- a lot of medical care, a lot of people who lost homes. It’s the reconstruction that’s the problem. It’s rebuilding. That money, a lot of it is tied up, it’s quite literally tied to aid or tied to some conditionality and hasn’t arrived yet. Schools, roads, water, hospital systems. We regard the Mirebalais hospital as reconstruction, not relief.
Dahl: That’s where more of the focus has to go. But I do think people get stuck, almost creating a rut in the ground saying the money hasn’t been well spent so we shouldn’t release any more money. We don’t think the Haitian people deserve this at all. It takes a while to rebuild. If you want to, there are all sorts of ways to do things like monitor how money’s being spent.
Q: Will the return of Jean-Claude “Baby Doc” Duvalier have any impact on the work you do and the reconstruction?
Farmer: I have no idea. It just seems to add more turmoil. I can’t see anything good that would come out of it unless there’s accounting for crimes.
Dahl: It doesn’t take a lot to mess with a fragile system. Finding ways to support democracy would be the most useful thing anybody can do. He doesn’t have a history of wanting to support democracy or not sabotage it.
I keep thinking about that famous photograph of Baby Doc, him and Michele Bennett driving out in that car, speeding out of Port Au Prince and she’s smoking like she’s going to a hair appointment. And that was so huge for Haiti. And I just didn’t think I would ...
Farmer: Live to see it?
Dahl: No, I didn’t.
Q: How can a person living in Los Angeles without contacts in Haiti help?
Dahl: Doing a little bit of research into the organizations you’re giving your resources to. Don’t go down and dig pit latrines -- Haitians need those jobs.
Farmer: Some of these camps, in Parc Jean-Marie Vincent, which is about 51,000 people in one little tiny space, they have 286 latrines. Plus, it’s dangerous for women to go to them at night. In Port Au Prince. The numbers are pretty scary. Like with vaccine production, can’t there be a much more ambitious endeavor? We keep talking about Depression-era interventions -- WPA, Civilian Conservation Corps -- that engaged millions of people otherwise idle in public good. Even if half the aid pledge gets in, imagine if that money could go towards creating jobs for people. ... We’re all for moving capital back to Haiti -- the way it’s done is what’s important. If you had to choose between conventional aid programs with a lot of use of contractors, lots of overhead, dumb trainings. If you had to choose between that and lots of money going into creating jobs for Haitians, we obviously vote for the latter. If you want to support good work in a place that’s troubled, you have to do some homework.
-- Molly Hennessy-Fiske in Larchmont
Photo: Dr. Paul Farmer, right, and Ophelia Dahl. Credit: Kirk McKoy / Los Angeles Times