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You don’t know who Paul Farmer is ?!?

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From the archives: October 2004

Yesterday I finally had the chance to meet Paul Farmer of Partners in Health (PIH).

If you haven’t heard of him, just think Mother Teresa with a Harvard MD/ Ph.D, a comfort in articulately dressing down the powers that be using Powerpoint slides, a few uncomfortable data points and a relentless rhetoric. He alternates his time between selling the world on the fundamental human right of the poor to the same standard medical treatments that the wealthy (or, in Paul Speak, “well resourced”) enjoy and delivering said care to impoverished communities in the world’s “resource poor” areas like Haiti, Peru, and Siberian prisons.

This is a man whose constituency are the poorest of the poor. In his world, South Africa and Brazil represent the well-to-do.

I’d heard a lot about Paul over the years from my friend Becca who is embarking on a similar career of living mostly in “underresourced” settings so it was nice to see this figure who has been so influential in her life and many others.

If you want to learn more about the specifics of his incredible life to date, Tracy Kidder has just written a book about him or you can listen to an archived NPR interview with Farmer.

I come from a background of mathematical equations, theoretical constructs, and economic models. You start with a set of assumptions and then derive logical results. If the real world does not look like your model, then you have to go back and study your assumptions since the results are mathematically derived and must follow.

This has been a very useful paradigm for me. You take a simple model that is easy to understand and then you focus on the assumptions – everything is about the assumptions. What exactly are you assuming? Are they correct? Are they static (do they look different under different scenarios)? Does it matter if they are not entirely correct? In what cases does it matter if they are not right?

For me, the model is simply a tool and becomes a means to understanding, not an end in itself. That is true for the Black-Scholes option model, software code, supply and demand models and portfolio theory. I have found myself a lonely figure in believing that a model is simply a starting point rather than the goal.

*Perhaps* I view everything through a certain set of glasses, but I saw Paul’s talk yesterday to the Stanford community as a scathing critique of people’s ability to appropriately use models, particularly in the context of the world’s poor.

His first point was simple. If (anytime you see an “if” you know it’s assumption time) we really do believe in certain human rights as espoused in documents like the Universal Declaration of Human Rights, our laws and spending should reflect those rights. If they do not, we should fix them.

What he implied, but did not say outright, is that if we don’t make changes, it must mean that we believe that the poor do not have the right to proven and widely available life saving interventions like TB drugs or AIDS anti-retroviral drugs since we have the money required to save the millions who now die unnecessarily from infectious disease.

The money is there, if not allocated. In the context of a world economy of more than $30 trillion, the discussion of whether it costs $5 or $10 billion a year to keep alive the millions afflicted with a treatable communicable disease is an example of a discussion where the assumption being off by a factor of 2 or 3 doesn’t matter—for many reasons. We can afford to reallocate 0.002% or 0.005% of our income with those who did not have the good fortune to be born in an OECD country. In dollars and cents, this means contributing $50 for every $100,000 we earn.

Paul’s second point was how much time his group spends overcoming inertia supported by a misuse of assumptions. An example: in the 1990s a common refrain was that patients with drug resistant TB in the third world generally die because it is too hard and expensive to treat them. As Farmer puts it, ”Is this the end of a conversation or the beginning of an interesting one?”

His group did a small scale study using local health care workers to treat patients in the slums of Lima, Peru in which most of the sick were quickly cured – disproving the “too hard” assumption – it simply wasn’t true.

Evaluating the “it’s too expensive” assumption was more complicated. The drugs used to treat people infected with a strain of TB resistant to the drugs commonly and cheaply used to cure patients were very expensive. But why? They were cheap to produce in quantity and off patent, meaning that anyone had the right to make them. It turns out that because there wasn’t demand for them (because the world had determined that the only people who needed them couldn’t afford them) no one other than the original manufacturer was doing so.

Always go back to your assumptions. You will learn a lot about the problem by studying them. And if your starting assumption is that basic health care service is a human right you will spend a long time looking at the assumptions when they lead to conclusions that deny those rights.

I think we can all learn from the experiences of Paul and his group Partners in Health. These are some thoughts I had following the talk, reinforced by my own personal experiences.

1. If we read the declaration of human rights and believe them to be true – we need to ask hard questions of ourselves and our communities.

We can go to the extreme and like Paul, work in countries like Haiti, or we can find ways to help the poor closer to home.

Most of us can certainly write checks to support the efforts of those who are working to remedy the current situation of extreme inequity.

Whether we can or cannot make a difference remains a philosophical discussion until we actually start doing something.

What steps, even baby steps, can we take to respect these rights?

Contributions can be in time, money or even made by supporting political leaders who will do more to address our responsibilities as members of the human race to each other (Paul’s group definitely accepts cash contributions ).

2. Start. Just start.

When you have a problem that you are told is really big and hard but needs solving, you need to dig in. It is only in the course of doing that you can begin to understand the true challenges and true solutions. This is equally true of development projects and developing software. Starting small, reassessing and then getting bigger is a good general model to follow when other efforts are not getting you anywhere.

3. Anytime you hear a statement or result that’s designed to “end a conversation” is the beginning of an interesting conversation.

These are the conversations that lead to breakthroughs – in medicine, in business and in life.

4. Beware of the tendency for scientists (social and otherwise) to lose the forest for the trees.

This usually manifests in obsessive attention to the details of the model that don’t matter. In economics, this means a confusion between economic and statistical relevance (which has become a datapoint of its own).

In public health, there are many who have become so obsessed with precisely measuring the gruesome impact of bad water on health that they have lost sight of the real question which is what can be done to clean up the water. In this case, the model will spit out a result that you want to get pathogens out of the water regardless of whether someone gets diarrhea 4 or 5 times a day. My friend Becca had to write an editorial this year in the leading British medical journal to shake her colleagues out of their analysis paralysis. Again it’s about the assumptions. Are they right? Which ones matter– and which ones don’t.

5. Number crunchers need to take some responsibility for the numbers they produce.

While none of us can be held accountable for all ramifications of the work we do, data people need to adhere to a similar standard that doctors espouse, “do no harm”.

Someone did a study showing that it was more cost-effective to spend a dollar on the prevention of AIDS than the treatment of patients with the disease and pronounced that all donations should go towards prevention.

This was almost a death sentence for millions and millions of people.

Let’s look at some assumptions in this analysis. The high cost of the drugs regime was taken as a gien. Thankfully some people did not take this assumption as fixed and worked to change it. The last thing I’ve heard is that the Clinton Foundation has just negotiated prices down to $140 a year — a significant improvement from the more than $15,000 the same drugs cost in 2000.

Farmer would probably say that the unspoken assumption in such a study is that as a society we have a choice not to treat third world patients with the same standard of care anyone with AIDS in the US receives and hence violate their human rights. The same researchers could have framed their study in an entirely different light — look world, given that we have to treat sick patients and that’s expensive, pony up some more cash that can be used to prevent infection – instead of their plea to stop treating AIDS patients.

Another implied assumption is that a hypothetical person who does not have the disease should be interchangeable on a one-for-one basis with an actual victim with a name and family. We as a society do not generally make choices that reflect this assumption (in economic parlance, we “discount” future uncertain outcomes). As they say, an ounce of prevention is worth a pound of cure (the 16:1 ratio of cure to prevention in the proverb is coincidentally very close to the estimate the authors of the paper get, using current drug prices).

Furthermore, what right do we have to make that difficult choice for the affected societies?

As Executive Director of the Global Fund to fight AIDS, TB and Malaria, Dr. Richard Feachem puts it:

“Cost-effectiveness analyses can be well used and it can be stupidly used… I was driving across Uganda with an economist… and we came upon a horrendous traffic accident. A school bus had collided with a truck. Children were lying all over the road. Some were dead. Some were dying. Others were seriously injured. I said, ‘hurry, hurry let us call ambulances and get these children to hospital quickly. Many of them maybe saved.’ The economist said, ‘No! Let us drive on to Kampala, to discuss seatbelt legislation with the government. It’s more cost- effective.’ The Global Fund will not be calling on that economist.”

6. It is important for policymakers and policy influencers to stay close to their subject.

Despite his status as one of the leading figures in global public health, Farmer still spends a good portion of the year in clinic treating patients. Only Farmer can say why exactly he does so but I would imagine the rewards are more tangible than the slow grind of wearing away at prevalent attitudes about the impossibility of delivering basic human rights to all the world’s citizens.

I think many people would be better at what they do if they did the same.

This means principals teaching a class, people expounding on privatizing social security offering financial planning services to the low and middle income, and CEOs spending a day or two in their employee’s shoes.

The end.

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