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An Interview with the late Paul Farmer, MD

In the spring of 1995, Paul Farmer was in San Francisco to take part in a weekend conference on resurgent TB. This interview —all too timely today— was conducted for the Anderson Valley Advertiser.

Paul Farmer runs a clinic in rural Haiti, where tuberculosis is the leading cause of death (and has been for centuries). He is 35. With his wire-rimmed glasses and radiant intelligence, he resembles a taller, thinner Elvis Costello. He was born in Massachusetts, grew up in Florida. There were six kids and the family residence was a bus. Farmer went to Harvard Medical School, and is now on the clinical faculty there. He has an arrangement that lets him spend eight months of the year working in Haiti. 

The following paragraph is the abstract (summary preceding a scientific paper) of the talk Farmer gave at the conference.

In much of the world, tuberculosis remains the leading killer of young adults, in spite of the fact that effective chemotherapy has existed for 50 years. The epidemiology of TB, with its persistence in poor countries and resurgence in many developed nations, causes consternation among those charged with protecting the public’s health. Two factors, ostensibly biological in nature, are commonly cited to explain this setback: the advent of HIV and the emergence of TB strains resistant to multiple drugs (MDR TB). But these biological developments are best understood as sociomedical  phenomena. The strikingly patterned occurrence of MDR TB —in the United States afflicting those in homeless shelters and in the inner city, for example-- speaks to some of the “large-scale social forces at work in the pandemic, which began before the advent of HIV. These forces (which include poverty, economic inequity, political violence, and racism) are examined through the experience of a young Haitian man with MDR TB, a disease never before described in Haiti. Insights from this case, and from other research on TB and HIV disease, are considered in an appeal for a new holism in future sociomedical research on MDR TB.

Farmer flew back to Haiti via Miami on Sunday. A colleague asked if he had an e-mail address. “No electricity,” Farmer explained. He works in an area where the small farmers have been driven off their land and the valley flooded to provide more hydroelectric power to Port-Au-Prince, where 95 percent of Haiti’s electricity is consumed. 

AVA: The news from Haiti suggests that powerful forces are now trying to frame Aristide for the murder of his opponents. The old day-is-night, night-is-day approach to politics that seems to work so effectively. 

Paul Farmer: In today’s Chronicle story the American ambassador is blaming the Aristide government for the assassination of 27 opponents.  Couple of things to say about that. I doubt it’s more than two who were opponents of the Aristide government. I have no idea who killed the Macoute lawyer. Mireille Durocher Bertin. There are rumors flying around that it was the Minister of the Interior, whose name is Beaubrun.  First of all, it seems like a very absurd thing to do, to kill someone when their power is at its ebb. After all, her power depended upon the active support of the Haitian military. She was lawyer and spokesperson for the coup. Killing her would be the very last thing you’d want to do, given that the Aristide government had returned to power --and given the way he did return to power, indebted to the international power structure. So the last thing the Aristide government would want would be to have someone like her killed. It would make no sense. Beaubrin may have been a former Macoute himself; the rumor is that he was a former military person put into the new government against Aristide’s wishes. 

This aside will make me seem very uncharitable, but I had  a patient who was gang-raped inside police headquarters in Port-Au-Prince --very, very brutally,  she was very badly injured, a 23 year old, and it was clearly political because she’d been arrested previously on a couple of occasions. And I told her I thought she should come to Boston where I could treat her and where she’d be a little safer. And I helped arrange a visa for medical treatment, which was not easy. And shortly after I began treating her, there was a special on CNN on rape as a political weapon in Haiti. And in the middle of it they introduced Mireille Durocher Bertin, who’s a very attractive lightskinned woman who speaks English beautifully, and her comment was that these women had not been raped, they were all lying, just to smear the reputation of the Haitian military... Think of what that means: to get time on CNN to say that women who are being raped are not being raped; to falsely portray a very critical issue in the eyes of the international powerful....

The other 26 people --I know one of them. Went to his funeral. He was a bystander in the killings. He was an airplane pilot who was trying to get some money back from a plane of his that had been confiscated or something like that, and he was in fact on his way to get the check. The legal conduit was supposed to be this woman, Mireille Durocher Bertin. From my own experience I know perfectly well that that was not a political assassination as the papers are suggesting. 

The other 25, I don’t know, but I can tell you, the majority of those people are victims of crimes committed with the guns that the pro-democracy forces pleaded to have removed from the scene last fall. You’ll remember, after the occupying forces came in, they were reluctant to disarm the attaches and the former military. And that’s where these guns are coming from.

I have another friend who was shot in this period. He survived, fortunately. We all believe he was shot by these same sorts of people. I have another patient who took a lot of machine gun fire in the face.  Several other people were killed that day. Now who has machine guns in Haiti? The flow of automatic weapons is easy to discern.  My reading of this recrudescent violence is that it’s a manifestation of the failure to disarm the attaches and military last fall.

Those of us who called for the complete disarmament said, “If you don’t disarm them, they’re going to start using these arms for their own fundamentally apolitical ends --to extort money from people.” I don’t know about Mireille Durocher Bertin. She was a very political Macoute figure, and her death could be political. But the last thing the Aristide government would want would be a death like that on its hands. Hence the notion of a frame-up is a very compelling one. Almost everyone in Haiti feels that way.

[The New York Times in a front-page story Tuesday, April 11, reports that the FBI is in Haiti investigating Bertin’s killing, but has no leads.  ”The killing has become a rallying point for members of the old ruling elite, who flocked to Mrs. Durocher Bertin’s funeral, attributing the shooting to President Aristide’s supporters, saying it proved how dangerous they are... for the Aristide Government, which denies involvement, the killing was a profound embarrassment, coming on the eve of a visit by President Clinton, and a source of friction with the United States.]

AVA:  The very first thing Clinton did upon being inaugurated was to turn away the Haitians fleeing the military. With that phony paternalistic speech, “These poor people are drowning in their makeshift boats...”   

Farmer:  One reading that’s common in Haiti is, Clinton and Bush are different. And that Clinton stabbed the Haitians in the back as soon as he was inaugurated. But they credit themselves with pressuring him to get Aristide back in --whether through leaving the country in boats, or political demonstrations in the United States....  I’ve been asked, “If tomorrow Clinton named you his Haiti point man, what would you do?” And I said, “Well, first I’d resign. And I would start working more with community-based organizations, civic groups, churches, schoolchildren...” There are possibilities for developing parallel tracks of foreign policy that have nothing to do with official channels except to upgrade, chastise , and resist them. The hope that we have for Clinton is that some persons in high office like that might feel slightly more accountable for whatever reasons --usually not good ones-- to the critiques that they’re receiving from the sectors I just described.  There are some chains of high command that are perhaps more malleable, or less immalleable. Does that sound too hopeful?

AVA: How bad is the ecodisaster --you keep hearing that all the top soil is gone, that Haiti is overpopulated, that it could no longer be a self-sustaining agrarian economy.  How could Haiti thrive again?  

Farmer: Haiti is an ecodisaster. Haiti cannot sustain a rural agrarian economy with seven million people living in it. How can it possibly survive? There has to be a means of recovering all the resources that have been stripped out of the country. There are three main models for looking at Haiti’s future: charity, development and social justice.  Forget the fourth main model, which is “Let’s trash it even further. Let’s use it up.” Let’s say those people can be held in abeyance for some time...  So one model is charity. There are going to be people of goodwill who are going to feel sorry for the Haitians and are going to start giving them things like shoes and shirts or fertilizer or whatever. I don’t want to be leveling my guns at these people. I don’t think there’s anything wrong with charitable instincts --as long as those charitable instincts are underpinned by good, solid analysis of what really happened. And I think usually when people go back and look at the historical record carefully, they actually abandon charitable approaches and look more at social justice work,  

The second way of doing things is development, and that tends to be the province of technocrats and experts who work with USAID, the World Bank, the International Monetary Fund, and even the World Health Organization. They’re trying to apply scientific knowledge to Haiti’s problems. And sometimes that’s very helpful. I certainly rely very heavily on scientific and medical knowledge and technology.  But I don’t think that an absence of that knowledge is the source of Haiti’s problems at all. 

I’m borrowing some ideas from dependency theory, which was developed in opposition to the idea that Latin American nations were backwards and poor because they were too isolated from the rest of the world. Dependency theory said “No, that’s not the case, they’re backwards and poor because they’re too tied into the rest of the world, which is ripping all these resources out of them.”  The same objection applies when you’re looking at the future development of Haiti. Haiti has not been driven into the ground by an absence of technology. Therefore, bringing in new technology and experts is not going to help them in and of itself. I’m all for the technology, but I’m also for making sure that it gets into the right hands, that it doesn’t get used to entrench the interests of the established elites, making sure that it isn’t used against people, as it so often is.  I’m working in an area of Haiti that has been a victim of development --a hydroelectric plant which, on paper, was to help the agriculture infrastructure of Haiti further downstream. But in fact the electricity is all sent to Port-Au-Prince, where it gets used by the factory owners and people who control Port-Au-Prince

The third model for looking at Haiti’s future is the social justice model, and that is what most Haitians really keep trying to achieve. From late ‘85 on, that’s all I heard. Haitians who are poor --the majority-- are neither naive nor vindictive. It’s not “the rich have our things, let’s kill the rich and take them back.” It’s much more humane and generous, but it’s also much more complex. They know about Haiti’s role in the world economy. They know about the role of the United States.  They know about the slave plantations. They know how things flow in and out of Haiti.  This is the Haitian poor I’m talking about, the peasants I live with. What they want, I think, what they’re asking for when they keep asking for “justice” is not just having a bunch of Macoutes tried and put in jail, but... What does it mean when you say that Haiti has an external debt of eight hundred million dollars. One could say, and should say, “Oh no! Haiti doesn’t owe the rest of the world anything. It’s the rest of the world that owes Haiti something.” 

I think there’s a big difference between the social justice approach and what the World Bank is trying to do with this five to seven hundred million dollars that they’re quote-unquote giving Haiti. I think if you had a much smaller amount of money put into Haiti with the social justice view behind it, you could do more than the huge amounts of capital that are coming in through various loan programs that are not very favorable, programs that are going to entrench the elite even further, programs that are not designed to address the basic needs of Haiti, which are the result of a long process of impoverishment. 

AVA: What would happen where you work if a social justice model were pursued?  

Farmer: This village is classic because they’ve already lost their land, and they want it back --or they want some other resources so they don’t have to be living on the edge. Their experience is emblematic of the experience of many poor Haitians. Maybe it wasn’t a dam, maybe it was loan shark, maybe it was a local heavy, but a lot of people have been immiserated over time. So what are the practical implications? We need land reform. We need to elevate the interests of the poor above the interests of a small and greedy minority who in the past have always controlled everything.

AVA: Is that Aristide’s goal? 

Farmer: It was Aristide’s goal. Can it be Aristide’s goal when he is so heavily indebted to the international power structure? I doubt it, but I don’t think that says anything bad about Aristide. I think it’s just very instructive about the nature of the late 20th century. If you look at other attempts to resist this World Order, which doesn’t seem so New, usually things haven’t gone well for the underdog. Even Michael Manley in Jamaica, who tried to resist the IMF --he lost, IMF won. And I suppose IMF is winning everywhere. That’s not a defeatist insight, it only means that relying overmuch on banks to solve the problems of the poor is probably not a very good strategy.

One Comment

  1. jonah raskin March 8, 2022

    Thanks for publishing this. Very informative. Great interview.

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