Ebola: Beyond the Headlines by Dr. Paul Farmer (Transcript)

He’s one of the founders of Partners in Health along with Jim Kim, who’s now at WHO.

Paul Farmer – Founder, Partners In Health and Harvard professor

World Bank.

Jacquelline Fuller – Director, Google.org

Oh, sorry. World Bank.

Paul Farmer – Founder, Partners In Health and Harvard professor

Makes a big difference. They’re the ones with the money.

Jacquelline Fuller – Director, Google.org

Yeah. Even better. Even better. And Partners in Health, if you’re not familiar with their work, is really proving what’s possible to deliver health care in the poorest settings. And Paul is also chair of Global Health and Social Medicine at Harvard Medical School, where you started, right, stealing medicines for the poor. He’s the chief of —

Paul Farmer – Founder, Partners In Health and Harvard professor

That goes direct to NSA here.

Jacquelline Fuller – Director, Google.org

He’s the chief of Global Health Equity at Brigham and Women’s Hospital. He’s an adviser to the UN Secretary General on community-based medicines and lessons from Haiti. He’s an author, of course, most recently To Repair the World: Paul Farmer Speaks to the Next Generation. And we do have copies for sale in the back, if folks would like to get his book.

Many people know of Dr. Farmer and heard of him because he’s the subject of Tracy Kidder’s biography, Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World.

In fact, show of hands. Raise your hand if you’ve read that book. So most of the room is raising their hands. Actually–

Paul Farmer – Founder, Partners In Health and Harvard professor

Raise your hand if you’ve read Women, Poverty, and AIDS. Thanks loads.

Jacquelline Fuller – Director, Google.org

Yeah. All right, but I’m going to ask a serious question actually. Raise your hand if that book, Mountains Beyond Mountains, changed your life in a significant way.

Paul Farmer – Founder, Partners In Health and Harvard professor

Raise your hands if Women, Poverty, and AIDS.

Jacquelline Fuller – Director, Google.org

So just one last note that Paul is also speaking tonight in San Francisco at City Arts and Lectures at 7:30. So if you don’t get enough this morning, or you want to bring friends, invite friends, there’s another opportunity tonight.

So we also want to say thanks to Paul’s colleagues and team who are here. Cassie is Chief of Staff, his cousin Ann is also a Googler, so well represented.

So Paul, why don’t we start just with a little bit of background about Ebola itself. So, tell us what are the most important things that we need to know. Why is this epidemic scaring people like no other, and where do you see it headed?

Paul Farmer – Founder, Partners In Health and Harvard professor

You know, one of the things that’s important to know is — you don’t have to know the kind of virus it is. That’s not that important.

What you need to know is I’m pretty sure we know where it comes from and how it’s transmitted. It’s a zoonosis, as everybody knows. But what’s happened —

Jacquelline Fuller: Meaning it comes from animals.

Paul Farmer: It comes from animals. It jumps from animals to humans. And what happened — and this has happened with every outbreak — is that primates or not, human or nonhuman, or not that the host, right? We’re accidental hosts. And so there’s a lot of speculation – you’ve probably already read about this that it’s from eating bushmeat, or a fruit bat with butterfingers — very clumsy fruit bat drops a piece of half-eaten fruit, and some kid.

Wherever it came from, that’s not what’s going on now. What’s going on now is person to person transmission because of a failed health care system or systems, because it’s a region, right? It’s also — that’s one thing. And there are other ways it can be transmitted. It’s person to person. When you hear about burials or funeral rituals, still that’s person to person transmission. The virus can be excreted after someone dies – is excreted and infectious.

But as far as we know, it’s not airborne. It’s spread through infected secretions.

Second point, I think, I would just move up on the list is that you hear that the case fatality rate is really high, but what does that mean? It means that a lot of people who get the virus are dying. But it doesn’t mean that they should die. And just for the sake of argument, I’ve been saying — again, just for the sake of argument – what if it’s not the case fatality rate that should be 90%, it’s the survival rate? And if we had that as our supposition, then we’d say, as you guys say at Google, how are we going to work against this goal or this plan? And if the goal or plan is let’s make sure everybody survives, then we have to work really hard to make sure that people are diagnosed early, that they’re given proper care. Because even without a specific therapy in anti-viral — and there are people — I don’t want to talk about this — we do have treatments for people who have — present very often in what’s called hypovolemic shock.

Ebola – Initial symptoms

So when you have Ebola, some of the first things that happen are abdominal pain, fever. Even with a fever, you start losing fluids. And then you have vomiting, diarrhea, and just as with any other cause of those symptoms, you’re losing electrolytes, you’re losing fluids, and the treatment is fluid resuscitation. And any American emergency room can do that. Even when someone can’t drink, oral rehydration, like Pedialyte.

So we’ve got to remember that we’re losing people who — there’s not a lot of T in the ETU – Ebola treatment units. That’s the second thing. I’m only putting it in this order because these are things I’d like everybody to know.

The health systems issue, that we’ve got to do better. And just to throw out another one – now there’s finally attention being turned to Ebola. We should have done it a long time ago. I don’t know if my friend Dan Kelly’s in the room yet, but we were in Sierra Leone, where he’s worked for a long time, in early June. Ebola had already crashed into the city, and it’s never done that before. It’s been an isolated outbreak, rural areas. That’s where it started.

But once it gets into the health care system — Here’s the third thing that I think is worth keeping in mind.

Disease of caregivers

It’s a disease of caregivers. Not just doctors — nurses, nurses’ aides, but who does the majority of caregiving?

Jacquelline Fuller: Women.

Paul Farmer: Women. Your mom. Women. Women — your mom, your sister, your aunt. So even the story from Dallas — and it sounds to me like the Good Samaritan. That’s the way I read. Some guy trying to help a pregnant woman who has Ebola.

And so those are three things that just wouldn’t come up on the first blush that I think it would be good to get into popular consciousness. There’s a lot we can do. This is not a new kind of spread, as far as we can tell. We’ve got to protect our caregivers.

Jacquelline Fuller: Okay. And then just to set the scene a little bit. Some people might not have the full context. You mentioned Sierra Leone. I was there a couple years ago, and I remember I met the only pediatrician in all of Sierra Leone. I mean, so you’re talking about a country where the health system is already pretty fragile. And then something like this hits. So maybe a word about how this is impacting the health system. What response is in place? What can we do?

Paul Farmer: Well, as you know, Jackie, concision is not my strong suit. But I will say a word, and that is, it has already made the health system fall apart. So that is also a done deal. The epidemic’s out, and it already 3took down the health system — in Sierra Leone and in Liberia.

Jacquelline Fuller: So that means that people with malaria, people with road accidents — I mean, it’s cascading effects.

Paul Farmer: That’s right. Exactly. And I think the same is true of Guinea. I haven’t been there, but talking to Guinean officials, I think they’d say the same thing. It’s having a very adverse — the majority of Ebola victims won’t have Ebola. They’ll have malaria, obstructed labor, some other problems that they would have ordinarily had taken on.

So that means that our work in emergency response — our collective work has to be linked to rebuilding that system, and to strengthening local capacity. Yesterday, a lot of you know Larry Brilliant. Dr. Larry Brilliant, who’s now at Skoll Global Threats. But we were at a conference, and he said, outbreaks are inevitable. Pandemics are optional. And that is pretty pithy, right? Because you have to miss all these chances to have a pandemic like this. And once it’s in the global economy, where people move around, it’s really harder to stop.

Jacquelline Fuller: Well, maybe just expand on that a bit because, I think for folks outside of the public health world, even understanding an outbreak versus an epidemic versus a pandemic and the impact that that can have, both in terms of morbidity, mortality, people getting sick and dying, but also economic impact on a region. So right now, we’re looking at while the official numbers have confirmed there are only about 7,000, right? But the estimate is that it’s just tens of thousands unreported.

Paul Farmer: We know that the doubling time just using reported cases — and again, I’m sure this is obvious to all you nerds out there — that reporting capacity is related to health systems, right? Strengthening.

I was recently in rural Liberia, and talking to a health official, and there are very few. It’s a thin — although they had stood up an effort beginning in March, even out in the rural areas. And I was asking to figure out the diagnostic capacity, is there a lab of fever here? And because I knew it’s the same for us where it is elsewhere. And the answer was no. But what she really meant is, we don’t have a lab.

So there is this problem also of, well, what fraction of the cases are reported, as you just said. And the modeling exercises, as I’m sure people saw last week — some of them are pretty grim. But if you were talking about a more than a million cases, you’re also talking about inaction and failure. And I think we could stop that.

Jacquelline Fuller: Yeah. What do you think is — just so we can get our hands around how bad it might get. So now the deaths are in the thousands — maybe 4,000 or 5,000 infections, maybe in the tens of thousands. But predictions that infections could go up in the millions. It could spread beyond that. What do you think — what is the worst case if we don’t do what we need to do and can do?

Paul Farmer: Well, worst case is really bad. And you asked me to define outbreak. I mean, an outbreak — this was Larry’s point– zoonoses cause outbreaks, because there’s contact, and there’s a lot of it, between animals and humans. By the way, the humans are winning, as many of you know — meaning the animals are not doing so hot. And that isn’t because of Ebola. That would be because of us.

So an outbreak is just a general term. You can have an outbreak of two cases, right? I would say that this has never really happened before. I mean, it’s easy to say it’s never happened before. But to move into this part of Africa, into cities, into the health care system — a lot of that is new at that level. All of it.

Jacquelline Fuller: Because usually the outbreaks are closer to the bush.

Paul Farmer: Or they also have been associated with poor infection control practices. The first outbreak, for example, ran right through a mission hospital, killing the nurses and the nuns and the patients. And so this is how it started. But it was contained. And this time, it hasn’t been contained.

And to get back to the economic question — again, this is all over my pay grade, or out of my field of expertise. Actually, this is Dan Kelley, who just came in, who I was just talking about.

Even now, with the number of cases that are reported, the economic impact is already quite palpable. Because air travel, ports, cross border trade, and tourism.

Jacquelline Fuller: Decimated. Yeah.

Paul Farmer: They’ve already badly affected.

Jacquelline Fuller: Center for Global Development’s got some good graphs on that in terms of the aversion effect. That is, not even just direct loss from trade, but aversion — people just avoiding the entire region, and what that can do to entire regional economies.

Paul Farmer: So I think we’re already in trouble. The question is just, how do we get out? I mean, as a species, obviously, I’m all for thinking this is our collective problem. And I’m also happy that, as far as I can tell, the people in charge in those countries have said, we want help.

Jacquelline Fuller: Yes.

Paul Farmer: And that doesn’t always happen.

Jacquelline Fuller: No. There’s a lot more openness than we’ve seen with some other outbreaks.

So, all right. One last question in the how bad is it, or how bad is it going to get? And then we’ll switch to solutions, I promise. So we saw the first apparent case in the US Tuesday. Should we be worried in the US or other developed nations? Do you see this spreading in Europe? Asia?

Paul Farmer: I see it coming to Europe, but not spreading. I see it coming to the United States. Well, in fact, last week, I got to play Cassandra. I was just saying on CNN — first of all, they put in a room where I was supposed to be doing a talk show, and I’m the only human in there, looking around and saying, hello? Hello? 50 minutes. No human. Anyway, I said, okay, all right. I did it. I confess.

But when this disembodied figure came on the camera and said, well, is this going to come to the United States and Europe? I said, well, sure. Because, again, it’s a global economy. But I agree with the CDC director Tom Frieden. I think he’s right. It’s not going to spread here, because we have the ability to do what’s needed, which is isolate the infectious patient while actually giving him good care, and then doing contact tracing, which is, as he said, bread and butter of public health. And to do it, it requires a lot of resources. And that’s the right way to do it. And I think that would happen in the European countries I’ve been to. It’ll happen here.

So I think we’ve got a very good chance of seeing cases, but not of seeing much in the way of person to person spread. I mean, it will happen.

Jacquelline Fuller: Unless the virus mutates, and then —

Paul Farmer: Well, the virus will mutate, I’ve no doubt. The question of whether or not that will change is either its virulence or transmissibility. Viruses and bugs — they always mutate when we poke at them with antibiotics or other — so, parasites, too.

Jacquelline Fuller: Okay. So then, thinking about treatment, there’s been an interesting sort of debate, discussion, in some of the articles about what’s the best approach? And so you have, say, Medicines Sans Frontiers, on one hand, advocating a very patient centered focus, making sure we take absolute best care and best standards. You have WHO. CDC’s sort of more of a public health mindset coming in, saying, well, we need to try these community health centers. I mean, your thoughts on whether — if you were the czar in charge of Ebola, what would you do?

Paul Farmer: Well, first of all, I think that, unfortunately, no one is really advocating for a high standard of care yet. That would require, for the critically ill, critical care. There’s this confusion. People think that supportive care means holding someone’s hand. And if you’re in hypovolemic shock, then you’re just going to hold their hand while they die unnecessarily.

So I think we have a long way to go before we can say that there’s any real progress on the quality of care. And again, that’s not to criticize any organization, especially any that shows up early to try and save lives. But what it looks like a patient focused versus public health — we’re not even there yet, because we’ve got neither going on. And both could go on.

And the one thing I would say early on in the epidemic is every time we’ve tried to oppose treatment and prevention, we’ve failed. You integrate treatment and prevention. So if you can’t drag people, pull people in to your care, which involves what? Involves isolation. That word just means following infection control. It sounds bad in lay language, like supportive care sounds like singing kumbaya. Please don’t do that if I’m in shock. Please don’t do that anytime. I went to a Catholic youth organization.

So just as supportive care is not singing kumbaya and holding hands, so too is isolation just a technical term to prevent the infection from reaching other people. And the best way to do that is pull people in with good care and good service.

Jacquelline Fuller: Right. Giving them incentive to go, like, we trust that the system’s going to care for them.

Paul Farmer: Exactly. And feed them, and let them — imagine being shut out of modern medicine forever. There’s never been a collision of Ebola and modern medicine before that I know of. So then you have people showing up in space suits or something, and then you don’t see your family again. And if that’s going to happen, which it should, it’s got to be linked to a warm welcome and survival. And that’ll happen if we have food and medical care, and there’s a way to do it. And that’s where we should go and invest really heavily in improving the quality of care and making sure our public health is stronger.

In some countries that have been credited with stopping Ebola, it took really hundreds, if not thousands, of staffers to do the contact tracing — community health workers, especially. And that’s the way to go. So even though you’re right, everybody is saying a high standard of care versus public health, that’s been a dead end with every other epidemic I can think of.

Jacquelline Fuller: Well, you mentioned contact tracing. One of the things that we, at Google, have been thinking about across many, many teams is just what can we do? How can we be helpful? What can we do that’s differential? So Google.org — we’ve invested about half a million to some groups like Medicines Sans Frontiers, UNICEF, others who are doing contract tracing, thinking about how can we help with some of the best mobile tools available out there to help with epidemiology? We have our geo team, for example, that’s helping to do things, even like providing really accurate maps with roads and critical information on them. We have a creative lab group, for example, that normally works on general marketing that’s doing things like helping to create visual images to do communication, so that people in low literacy environments can understand how to take care of themselves, how to take care of other people, our crisis response team. This is happening in regions, obviously, where internet penetration is very low, so some of our typical tools in our toolbox are not as effective. But we’re looking at, can we be helpful in terms of people searching for information? OneBox is providing information and hotlines.

And Googlers, if you’re wondering what you can do, if you’re in the room, there’s a badge set up in the back where you can go and donate to Partners in Health, some other orgs on the front lines. You can also join Ebola Announce if you want more information about what’s happening at Google. But those are just some of the areas where we’re trying to think about how can we help in a way that best uses our strengths? But I’ll just turn the question over to you and say, what should Google be doing? What should the tech industry be doing? What should Americans, what should be the rich world be doing in general to help here?

Paul Farmer: Well, first of all, those sound like really just the kind of things that we need Google to be doing. I mean, there’s more, of course, it will not shock you that I think. And I’d just really like to formally introduce my colleague, Dr. Dan Kelly, who is — well, at least he was, until about a month ago, studying for infectious disease physician training — studying for an MPH. And he’s been working in Sierra Leone for some time. I said, well, time to go back to Sierra Leone. And we’re actually headed off together, along with our colleagues, in a few days.

So if you go out to the kind of places where WellBody Alliance works, or Last Mile Health, or Partners in Health’s other sister organization in Haiti, that’s Zanmi Lasante, which many of you have supported after the earthquake, a lot of the very tools you mentioned have not been available to the poor, right? It’s worse in those parts of Africa with internet penetration than it is in Haiti, which is bad enough. So we don’t know what’s happening where cases are popping up, and I’ve seen that already being useful — those technologies are already proving useful. And I would just encourage you all to keep pushing these out to the rural poor. The rural poor are the last ones to benefit, in my experience, from technological advances. And, again, there’s no reason that has to be the same next year as it was 50 years ago or 10 years ago.

So that last mile issue of going to the people really shut out of modernity — I think Google can push that, right? And another thing that I’ve found very helpful for 30 years is this idea of — which we stole from liberation theology — a preferential option for the poor. It’s kind of a simple idea, but very radical. Say you’re a doctor, and you can say, I take care of everybody, but my primary concern is people who are sick and poor. That kind of thinking too rarely invades foundations, educational institutions, universities, companies. And I’m only saying it because I think it’s really helpful, because that’s the big challenge. That’s another kind of last mile.

A third is don’t buy it when people say, well, this is a really straightforward intervention. It’s all about — and then fill in the blank. It’s all about prevention, it’s all about improving quality. It’s not all about either of those things. It’s really going to be hard, and it’s going to require the kind of tools that I think people here would take for granted.

Now, all that said, the other thing is, please be patient with us. You are the ones who are the Googlers and the engineers, not us. I’m a doctor. I don’t expect you to understand how to dose SafSlim or to use the right prophylaxis for malaria. I know that stuff, though. But we don’t know from engineering or from IT, well, some people on our team do, but not a lot of us, right? So we need you to be patient and to accompany us with the gifts that you have over the long term.

I said this after the earthquake in Haiti, and we did some of the things that we said we would do. I’d like to think we did all the things we said we would do. We did build that medical center in central Haiti. We did make it the largest solar powered hospital in the developing world. We did build a new IT backbone to connect it to the Harvard teaching hospitals so that you can see an x-ray in Boston at the same time that you see it in central Haiti. We did put a CAT scan — the first one in a public hospital anywhere in Haiti — in rural Haiti, and, again, connected it to whatever it goes through God or Google or whatever.

Jacquelline Fuller: We’ll go with the cloud.

Paul Farmer: That accompaniment is critical. We’re begging, be patient with us. You know things we don’t know, and we really need that. And then third, this kind of work needs resources that can be turned on a dime. Why do you think all these huge bureaucracies — they’ve been there a long time. The UN very humbly, when I was there, they were doing our transport in Liberia, because there’s no air bridge, right? The airlines aren’t flying, really. And it’ll be worse now that you’ve had a commercial carrier. I actually flew out, I just noticed, on the same day as that patient, or the day before, right? So I haven’t finished my 21 days either.

Jacquelline Fuller: Good to know.

Paul Farmer: If anyone gave me a hug. But it’s going to make it worse, right? So the UN was very grateful that they got us around, including in the rural areas. But they were saying, hey, we worked on this for 10 years, and then one epidemic, and everything fell over. And that’s the right humility, I think. Not everybody would say that, but they did.

So one of the problems is that if you study bureaucracy like the sociologist Max Weber — see, aren’t you scared that I’m going off with some —

Jacquelline Fuller: Yeah. Questions? No, just kidding.

Paul Farmer: Okay, I won’t quote sociologists. But that flexibility — that only comes from discretionary capital. You guys know that in business. You can’t not know that. We need that.

Jacquelline Fuller: On the subject of discretionary capital and what we can do — I mean, on your site — and this is something that we pushed when I was at Gates Foundation before Google is if you ask Americans how much do you think that we spend on humanitarian aid, the average guess is about 10%. And in reality, we spend less than 1% of our budget on humanitarian aid. So just sort of taking a wider view now from Ebola, just on global health in general, global development in general, it seems like we’re going to lurch from epidemic to epidemic to crises to crises until we spend some real resources in some real smart ways.

Paul Farmer: You know, I heard Jim Kim said something really remarkable the other day. Well, I’ve been hearing him say remarkable things for a long time. But he said that he spends a lot of his time talking people out of talking themselves out of doing the right thing. And that’s because we’re all so socialized for scarcity, right? And that’s a bad thing, because we can romanticize frugal innovation, but I don’t buy it. Sitting in the middle of a squatter settlement in Haiti, or in a rain forest with no electricity – that is a dangerous kind of romanticization in the middle of an epidemic. And so I know it sounds attractive, but we’ve got to have, like you said, more resources put into these problems.

I mean, none of us, if we were critically ill, would not want to have care, nor would we want our kids to settle for or get second best. That’s how most of the people I see in a clinic or hospital feel as well.

Jacquelline Fuller: All right. So we’re going to turn to live questions now, and we have a mic right there in the back. And then we’ll also take some from the Dory. Can we get the Dory questions up? Great. So while people are working their way to the microphone, what’s your message to the average citizen in the empowered world, in the developed world, on what can I do? What can an average citizen do?

Paul Farmer: Well, I think it’s better to imagine that there’s something you can do, even to respond to a problem that seems so remote from your own experience. And whether you call that empathy or — it’s not like pity or mercy are bad, either, right? Those are not bad things.

Jacquelline Fuller: We’ll take them. If I’m dying in that rainforest, I’ll take it.

Paul Farmer: Exactly, you know and we should remember that. Mercy is a good thing. In fact, back to my PTSD Catholic youth, it’s one of the cardinal virtues.

Jacquelline Fuller: Yeah.

Paul Farmer: On the other hand, if you could link that to solidarity, and then link that to pragmatics, that’ll really help with a problem like this, right? So in addition to watching wherever it is you’re watching, or thinking or listening or hearing about a problem that seems remote, I think right now, what that region needs most of all is some of that pragmatic solidarity. And they need help — material help with rebuilding a health system that could be more robust. After all, these are all areas ridden by conflict in recent times, and those are transnational conflicts. It’s not like something that happened just in Liberia or just in Sierra Leone. This is not like blood diamonds — like they’re wearing them on their hands, right?

So thinking about that pragmatic piece, and then link that to organizations that you have faith in.

Jacquelline Fuller: Like Partners in Health.

Paul Farmer: Like Partners in Health. I mean, we’re proud to be part of that. I’ll just give you an example — something that gave me chill bumps and moved me very much. An American actor named Jeffrey Wright got it that there’s something wrong here, that we can’t give up on people and think they’re all going to die when they have Ebola. And exactly what every doctor and nurse should have said, by the way. Wait, you’re telling me that it’s because they have hypovolemic shock?

Jacquelline Fuller: That’s treatable.

Paul Farmer: And that’s treatable. Or they’re losing electrolytes. And so he started a public service campaign about survival, and to get the message out that we’ve got to fight for people to survive. Don’t forget, when people survive, they become immune. That’s what it looks like to us.

Jacquelline Fuller: And gives hope to everyone else observing them.

Paul Farmer: That they can be part of the solution.

Jacquelline Fuller: That I don’t need to hide this. I can come forward.

Paul Farmer: And they can help us in our work. I’m not immune. They are. Now, not everybody’s going to want to work on that, but that’s just an example. People think, okay, there’s somebody who’s survived Ebola. What if they’re part of the solution? That’s what happened with AIDS activism. Let’s have Ebola activism. Let’s make sure that there’s a place for them to help. And I know it sounds kind of corny, but I feel that way about everybody about global health equity is that everybody can help somehow.

Jacquelline Fuller: And I think that’s part of the magic that ignited the generation is that every person matters, and that we need to do we can do to save everyone, because each life matters.

So first question. I see Raquel, who’s an engineer with google.org, and has helped leading our crisis response on this.

Question-and-answer Session

Raquel Romano: You said there’s not enough T in the Ebola treatment units, and that we haven’t really reached the highest quality of care possible. So what I want to understand is if there aren’t enough actual physical doctors, enough actual beds, enough capacity in the treatment centers? Because in a lot of conversations we’ve had with various people, all sorts of health organizations who we’ve been talking with to see how Google can help, one thing that we’ve heard — and maybe this has changed — is, well, we don’t need money. We need leadership and direction. And maybe this is more around some of the tech solutions we were talking about, but the sense that the money’s flowing in, but we need people who know how to execute, organize, connect, deploy, train. All these things. It’s people. But it seems like that may not be the case, if it’s really that we don’t have enough actual physicians.

Paul Farmer: Well, I don’t think that it’s true that we have enough money. First of all, a pledge is not the same, as you know, as delivery. That’s just the beginning of a process to get to the last mile. So again, I would say that is incorrect. I’ve heard it, too. It’s just not true. We need massive resources and a commitment to delivery. We’ve studied this now. In fact, we’ve used IT platforms just to ask a simple question after the Asian earthquake. How many of these pledges are actually delivered? And that’s just delivered to a place where they could be delivered as services.

Jacquelline Fuller: How of it actually hits the field?

Paul Farmer: And that’s just a national capital kind of thing. We found out the answer is not very attractive. So we basically need staff, stuff, space, and systems. We don’t have any of them.

Jacquelline Fuller: What’s the hashtag?

Audience: Staff, stuff, —

Jacquelline Fuller: Staff hashtag –

Paul Farmer: Is there a hastags – I like that. What’s a hashtag again?

Jacquelline Fuller: Oh my —

Paul Farmer: No, I have a teenage daughter. She explained it to me.

Jacquelline Fuller: We’re going to do a little session afterwards.

Paul Farmer: I’m not done. I’m just getting warmed up.

Jacquelline Fuller: Okay, you’re getting warmed up, but we’ve got people who it’s going to be the biggest moment of their life that they get to ask you a question, so —

Paul Farmer: You should just take one of my classes.

Jacquelline Fuller: And we’ve got questions from around the world too. So – but go ahead and finish, and then we’ll turn it over to our next question.

Paul Farmer: Well, I think we’re counting on your discernment and everybody’s discernment, because first of all, most of that critical care is delivered by nurses, not doctors. Go into the emergency room, the urgent care center – someone needs an IV. It’s nurses. And I think if you go in to your nurse or a physician — you go into an ETU and you don’t see this happening for all kinds of reasons. But the reason isn’t that it isn’t needed. Then, you know, we’ve got to be tougher on ourselves, at least on the clinical side, and say there’s not enough. Again, if it were you, I wouldn’t want you to have that kind of care. If it were me, I wouldn’t want to have that kind of care if I’m critically ill.

If I’ve got a hemorrhagic complication and a blood product will help me, don’t say it’s impossible to give blood. Let’s say, instead, we’ve got a long way to go on staff, stuff, space, and systems.

Jacquelline Fuller: And Partners in Health, along with a lot of other orgs, are the ones who blew up in this whole idea when people said we can’t treat AIDS in a place like Africa. We can’t treat TB. We can’t treat multi-drug resistant TB. Partners in Health has proved that we can do it, and do it in a very resource effective way. Takes the mentality.

Paul Farmer: Yeah. And I think it takes a different kind of idea, again, of who the team is. It’s the community health workers, but also the doctors. And if you go right through that list — don’t worry, I won’t– staff, stuff, space, systems — same things around AIDS. And again, just setting our sights higher.

Jacquelline Fuller: All right, we got another question.

Male Audience: Yeah, I was just wondering if you’d go a little bit more into what you think the sociological angle of health care in West Africa is, and how you think Weber work applies to that.

Jacquelline Fuller: Did you really ask him to quote –

Paul Farmer: He did. I’m so happy. I’ve been waiting for this since Google was founded. So Max Weber was this great sociologist 100 years ago who wrote some classics like “On Bureaucracy,” which I use in teaching global health. Because– and I’ll just say the short version, concision not being my strong suit– that his predictions about bureaucracy, policy, moving away from charismatic authority to bureaucracies, all have come true. And the only reason to keep that in mind is that every time you fix as policy a standard, what if something new comes along? It’s like a budget. You say, well, Ebola’s not in our budget. Well, that means that your budget’s wrong, not that the virus is wrong.

And sociologically or whatever, politically, this is what happens all the time. This is why you get big moral errors like, well, we don’t treat AIDS in Africa. And it’s absurd. And it happens every time. And then you have to fight like hell to say, okay, what’s the global health equity agenda? Forget about the plan that we had. If it didn’t have cholera in it, and cholera smacks Haiti, you’d better change the plan. You’d better change the budget. And that, again, is difficult when you’re socialized for scarcity, and everything is about, well, let’s do more for less. Look at the budgets of those countries from the public sector into help, they’re at India level per capita, which is very, very low. China’s up here. Rwanda’s above China per capita. That’s why Rwanda has such a strong health system is because they invested in it, and they brought partners in to invest in their plan, 2and they have to be able to change it, like I said, on a dime. And that’s hard. That’s where I imagine we’re stuck in that part of the world.

Male Audience: Do you have a book you could recommend or books about the kind of –

Paul Farmer: “Women, Poverty, and AIDS,” for sure. Say again?

Male Audience: Sorry. I was wondering if you could recommend a book that goes into the kind of setting of priorities in a bureaucracy that you were talking about, whether Weber or other people.

Paul Farmer: Meet me after class. Yeah, I do. I’ll write some down for you.

Jacquelline Fuller: And we’ll publish it on Go Paul Farmer, so people can have access to it, too.

So why don’t I take a Dory question from one of our other offices? So what do you think tech companies like Google can do to aid the efforts in building a better, long lasting health system in Africa?

Paul Farmer: Well, again, this issue of — hi, Dory. I wonder where they are.

Jacquelline Fuller: Who’s asking that question?

Paul Farmer: Can you tell? Ulan Bator. You know, it doesn’t matter. I was just curious.

I think one of the things that we could do, I mean that you could do is again, this accompaniment idea. Because if you look at the way that business is done contractually, contractors, a beginning, and an end, that’s not what we need, I don’t think. We need a long term accompaniment model. Because it takes a long time to build systems. You could say, well, we’re not in the business of building systems, but you are. That’s what Google does, right? And you do this in settings where there’s extreme poverty, no electrical grid. People tend to have their — and this is true, again, of all of us. Remember what Jim said. You spend a lot of time trying to talk people out of talking themselves out of doing the right thing. Accompaniment is a balm — B-A-L-M– for us from companies. And we just haven’t had that many experiences with companies or with foundations, sometimes. And we need more, because that’s the kind of fruitful relationship we would seek with a tech company.

Jacquelline Fuller: Okay. Let’s take another live question.

Male Audience: Hi. Correct me if I’m wrong, because I’m not a medical doctor, but a lot of the initial symptoms for Ebola are similar to the common flu’s initial symptoms. Do you think the media possibly drumming up an Ebola scare being in the United States could overwhelm the US health system to a point where the few Ebola cases possibly get overlooked with too many people thinking they have Ebola when they just have the flu?

Paul Farmer: That’s a possibility, and it happens every time there’s a big scare of one reason or another, right? I do think that with better diagnostics – let me just put it this way. I bet you everybody who’s working in an emergency room or urgent care center is thinking Ebola all the time now, right? And the day after the Texas case, the next morning, I was teaching in an infectious disease course, and I laid out a typical presentation. And it would’ve been malaria or typhoid, and half the room went, Ebola. It was Ebola, actually.

So I think having a heightened suspicion, as long you’re not forgetting the other, much more common and treatable causes, I think it’s probably a good thing. And we need better diagnostics, but right now, I don’t think it’s a bad thing to have this ridiculously heightened sense that what if it’s Ebola, as long as we know where Ebola sits in the burden of disease that could cause a fever, weakness, nausea, and vomiting. It’s extremely low, for sure, in the United States. And even in a place like some parts of rural Guinea or Liberia, it would still be extremely low. It would be much more likely to be malaria. But it’s good for everybody to be worried about it.

The problem is, as Jackie pointed out, is now that the primary health care system has tottered and fallen, getting it back up again is going to require linking that anxiety about one problem to linking that anxiety to all the problems that are common.

Jacquelline Fuller: Okay, so we have a question from one of our other offices.

Paul Farmer: Why five minutes. I came all the way from Monrovia, Sasha. I want another 50 minutes. This is your Friday. You guys — I know your famous work hour thing, where you get a —

Jacquelline Fuller: Yeah. We’ve got to get to our nap pods. No, I’m just kidding.

We’re going to actually have more time after this with Dr. Farmer and technologists, because he specifically want to spend some time with engineers. So if you’re interested in that conversation, we are going to stay a little bit longer. But in the last five minutes or so, especially for our remote offices, I’ll just tick through maybe some of these questions.

So you’ve said that understanding poverty and inequity requires many disciplines — economics, ethics, loss, sociology. Oh my gosh, you’re going to quote Weber again, aren’t you? In your experience in communities, what disciplines are missing, and what do they need to focus on once they come to the table?

Paul Farmer: You know, I think I can answer that with much more concision. I think history, because we are a desocializing species. Like, we can’t even remember what happened last year. So an anthropologist studying anthropology, a sociologist with sociology, a psychologist — forget it. It’s history. This is not the first rodeo we’ve been to. It is, as you pointed out, similar to HIV, or similar to the previous epidemics of hemorrhagic fever. And I think if only we were a little bit more rigorous with ourselves about looking at what’s happened before — not everything is new.

Jacquelline Fuller: We’re relearning some lessons again and again and again.

Paul Farmer: By the way, the prevention versus care, quality of care, when it’s poor, thinking it’s high — none of this seems strange to me.

Jacquelline Fuller: Okay. Next question?

Male Audience: Hi. So I read your review on Rishi Manchanda’s book, “The Upstream Doctor,” and I had a quick question about that.

Paul Farmer: How’d you like it?

Male Audience: Your review or the book?

Paul Farmer: My review. “Women, Poverty, and AIDS.” Sorry.

Male Audience: I’ll add that to my to do list. So given that upstream solutions aren’t the easiest sell — they’re long term plays to tackle the source of a problem, as opposed to the symptoms that people in the media focus on– in your conversations with world leaders, what has been the data or the primary factors that motivate them to be catalysts for change at the levels they operate in?

Paul Farmer: Well, I think it’s better to assume that their motivation is something good, and then entrap them into decency, right? You feel me? I’m serious. I think to approach leaders with a hermeneutic of suspicion and not engage them in a chance to do something decent is bad for people marginalized by poverty and racism and gender inequality, right? Don’t do that. We shouldn’t do that on their behalfs, to say it’s not worth working with so and so world leader.

The upstream downstream is another one of those classic lessons, right? Where there’s a sort of Luddite approach to upstream downstream, where we’re saying, well, the upstream determinants are all important, but if you’re already downstream — if you already have Ebola — like I’m saying, I want someone to be looking out for me. And I was just saying, I was at Stanford saying, oh, I was stupid enough to walk in front of a car when I was a medical student. And I didn’t have my M.D., and I looked at my leg lying in the street and thought, hey, broken leg. I didn’t even have my M.D. What a great diagnostician.

If someone had come over to me, leaned over me, and said, hey, you should have looked both ways before you cross the street — if an ambulance attendant did that, I would be really unhappy, right? That’s what we do to poor people all the time. We’re like, upstream downstream. Should have used bednet. Should have used a condom. Should have done this. Should have done that. History has shown us that we do that way too often. And so we can do downstream — that is, take good care of people — as we’re doing upstream — that is, prevent people from getting sick. And that’s an important thing to get across to world leaders as well. This is complicated, you know? And they want something simple or low cost or cost effective. And all these things change. Something that’s complex becomes simple. Something that is costly becomes less costly. Something that is effective becomes replaced by something that’s far more effective. And again, the bureaucracies can’t move rapidly enough. That’s, again, why we need room to move, and that requires resources. Again, staff, stuff, systems, blah, blah, blah. And that’s very hard, I think, for world leaders. They’re being told, here’s your budget, or here’s your plan. In fact, you get derided for wanting to change as fast as the pathogens do. You get made fun of. Which is imprudent, as we’re now seeing with Ebola. That’s a great question.

Jacquelline Fuller: Why don’t we have our last two questions? Just both of you ask your questions one right after each other, and that way we can get them in before.

Female Audience: Hi. For those who are surviving Ebola, there’s obviously a huge amount of stigma. And I’m just wondering how the health systems in West Africa are treating the survivors.

Paul Farmer: Well, I don’t know enough. But, again, to quote Jim Kim, we should hire every one of them. I think that’s exactly the right logic. And the health care systems and the neighborhoods, neighborhood organizations, church groups, whatever — I think that’s really going to be an important message to get out. And I’m quite sure that’s why Jeffrey Wright was working not just to get people in the United States or Europe who might see one of his movies. And, again, I don’t know — I guess that’s a kind of global phenomenon. I messed up again. But also to get the message of hope out in areas facing big burdens of Ebola disease.

So I think that’s just unfurling right now, and that we would do well, all of us, including those of us who are going to be working there for some time, to keep on underlining how much we need the survivors to be part of the solution, and that we’re with them. And I’m hoping that’ll change very rapidly. And the health systems — again, remember the health systems are underfunded and collapsed, so they couldn’t just say, okay, we’ll hire all of them, right? But we could. We could help them do that and strengthen the public health system by a relatively minor expense, right? One little happy thing — and I know you wanted both questions to be asked — is that when I was leaving Monrovia, they were just opening up a new Ebola treatment unit. And they was the Liberians, and working with colleagues mostly from Uganda. And it was the day before the grand opening, and there was a huge crowd in front of the Ebola treatment unit, and they were volunteers. And it was all Liberians. People want to help. And we’ve got to help them help, right? Because they have resources we don’t have, but we have resources they don’t have, and I think it’s going to be the same with the survivors.

Jacquelline Fuller: Okay, last question.

Male Audience: I have a couple of questions on the —

Jacquelline Fuller: No, you get one question.

Male Audience: On the disease Ebola itself. You mentioned that the survival rate is very low, because the treatment options are not that good. Do we know the growth room for how much better the survival rate could be if we had good treatment options? And the second question is I’ve seen all these pictures of people in space suits. Is that an overabundance of caution, or is Ebola really that infectious?

Jacquelline Fuller: That’s a good question.

Paul Farmer: Two good questions. He was right.

Jacquelline Fuller: And you can answer them both.

Paul Farmer: Well, I don’t believe it’s an overabundance of caution. And just to say one reason why, and then I’ll go to the other. It’s one thing to wear this gear in an air conditioned building, right? And even in the New York Times article a couple days ago about Nigeria’s response, they mentioned air conditioned hospitals. And in Haiti, when I’m about to pass out, I go into the surgery wing, because it’s air conditioned. I mean, really, pass out.

Now, there’s no electricity, so how’s there going to be air conditioning? Here and there, maybe, but how long can you wear that and be very careful? The people I trust most say about an hour, and then it’s disposable. Now, there must be other solutions. We need to talk to manufacturers who understand this. It’s too hot, right? And what does that mean, it’s too hot? You make a mistake, you get careless, you don’t have on the right coverage, it’s because people look at a video at how often people touch their eyes or their mouth. It’s not that it’s suddenly going through skin. So I don’t think it’s an excess of caution until we have the staff and the stuff we need to make it go very smoothly.

So the other point, which I’m very passionate about, is — this is just me saying live to the planet, or wherever this stuff goes —

Jacquelline Fuller: Live to the planet. Thanks, YouTube.

Paul Farmer: I think that we should assume that we are able to save the great majority of people already sick with Ebola. Why? What’s the risk in saying, 95% survival rate? Risk that I’ll look like a fool? I don’t care, right? I would like, as a physician and as a community health activist — I could care less if that sounds foolish to any of my colleagues. If we assume that 95% of people could be saved, and we — pardon me, but bust our asses to try and get them diagnosed and cared for early on and do everything we can, what’s the risk of having an excess of zeal, as opposed to an excess of caution? So I think that message of 90% case fatality is damaging. I’ve heard it before. What’s the case fatality rate of untreated pneumococcal bacteremia before we developed antibiotics, or for those who live outside of the antibiotic realm even today? It’s probably the same. It’s probably 90%.

So I think we should believe that we can flip those numbers on their head. This is a failure of delivery of basic supportive care. And when we address that, and we say, oh, you were wrong, it’s really 50%, that’s fine. I can live with that. But until we address the failure of delivery, I’m just going to assume, based on what we know about the critically ill from sepsis, whether it’s of bacterial or viral cause, or hemorrhagic complication, that we should be saving everybody. And if it’s not everybody’s job to save them, it is the job of doctors and nurses and their family members, right? That’s what their family members are going to care about — their mothers and their siblings and their children. And we’ve made this mistake before around every serious infection I know of, or cancer like acute leukemia in children. We’ve got to fight to do that part of our job.

Thank you.

Jacquelline Fuller: So a very important message from Dr. Farmer, I think, to all of us, charging us on towards pragmatic solidarity. I think for Google in particular, thinking about how we can lean in with our technology for the long term with a preferential preference for the poor. Gonna steal that, too.

Paul Farmer: I stole it.

Jacquelline Fuller: Yeah. So let’s all thank Dr. Farmer for coming here today, and his message for all of us.

Paul Farmer: Thank you very much.

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