Dr. Paul Farmer’s friends accuse him of being “pathologically optimistic.” That may explain how he’s managed to spend his life helping people in some of the most traumatized parts of the world: Haiti before and after the 2010 earthquake; Rwanda after the genocide there; West Africa during the Ebola outbreak of 2014-2015; and now the United States during COVID-19.
He’s sorely disappointed in how his home country has handled the pandemic. “There’s a lot to be done,” he said. But he remains confident that the pandemic can “be brought to heel.”
Farmer chairs the Department of Global Health and Social Medicine at Harvard Medical School and co-founded Partners In Health, a Boston nonprofit that provides medical care in developing countries and the U.S. His work is the subject of a recent Netflix documentary, “Bending the Arc.”
Farmer’s latest book, “Fever, Feuds and Diamonds,” published this month, focuses on the Ebola outbreak and the public health mistakes that made it worse.
He tells harrowing stories about people in Sierra Leone, Liberia and Guinea who lost parents, children or spouses – sometimes all three. He argues the outbreak could have been less lethal if the French, British and American colonial powers had left the region with a medical infrastructure, and if international efforts had focused on helping Ebola patients get better, rather than containing the disease’s spread.
With COVID-19 raging across the country and the world, Farmer talked with USA TODAY about what the lessons of West Africa, Haiti and Rwanda can teach us about our own struggle.
The upside of living with dangerous outbreaks
In the U.S., we tend to think of disease outbreaks as something of the past – the plague of the 15th century or the 1918 flu epidemic – not something that happens to us.
Farmer: There’s a long history of declaring plagues over. Not just individual plagues but all plagues. With the advent of effective and non-toxic antibiotics, there were declarations of the end of the infectious pathogen from the American Surgeon General on down.
Of course, that’s never going to happen. We live in uneasy symbiosis with viruses – they’re the worst, usually – bacteria, parasites. That’s the way it’s going to be.
That’s another reason for us to think really hard about our investment in public health and safety nets in the United States.
In many countries, medical scourges are still common. What can we learn from them about how to deal with COVID?
Farmer: Some of the places that I’ve worked in over the last 35 years, people are living in so much proximity to that kind of danger, that they know more about the lessons.
That’s one of the reasons Rwanda has done a great job of responding to COVID: They had just been trying to protect their western flank from Ebola when COVID hit.
They knew what contact tracing was (the process of identifying people who may have come into contact with an infected person). They had hired and trained, not just a few thousand community health workers to do contact tracing, but probably 60,000 in a very poor country of 11 million people.
We’ve had to struggle in every state in the union to get contact tracing elevated and supported fully, so when you call someone on the phone and say, “You need to isolate, you have a close contact (who has COVID),” that you’re able to provide the necessary support for those people (which Partners in Health does).
Some of these lessons are just closer to home in places that have not been spared the kind of risks we usually are spared here.
The nihilism crippling America’s COVID response
What concerns you most about America’s fight against COVID?
Farmer: We have clear evidence of “clinical nihilism” in a lot of places I’ve worked – the claim that there’s nothing we can do for this patient, they’re beyond recall, this disease is too deadly. All the things that were said again and again and mindlessly about Ebola.
In the United States, what I’m seeing now is a “containment nihilism,” where people are saying, “It’s too much for us to hope to contain this.”
What do you think is behind that sense of hopelessness?
Farmer: There’s been a real toll of under-investment and lack of clear federal guidelines.
Do you think that will change when Joe Biden takes office in January?
Farmer: I think it’ll help. Leadership matters, tone matters, how our leaders conduct themselves matters. But tone is not enough. We need to invest much more heavily in public health.
I’ve lost friends and family to COVID. I have friends and family who’ve lost their jobs or are furloughed. I’m waiting to see more relief and support for those people as well. I think there are innumerable things we can do.
The connection between masks and trust
What about masks? Are you upset more people aren’t wearing them?
Farmer: I never shame people for not wearing masks. It’s not the way I roll. COVID-shaming strikes me as no more appealing than shaming people around AIDS. I’m disappointed, but that’s not the way to move forward.
So why do you think people aren’t doing things like mask-wearing that clearly benefit both themselves and others?
Farmer: We’re dealing with an epidemic of mistrust.
You describe a similar epidemic of mistrust in West Africa during the Ebola outbreak. How did they counter that?
Farmer: Changes in policy and laws – that were, by the way, very unwelcome, often. I saw families who bitterly resisted a lot of these laws and rules, and were also deeply relieved by them, because they allowed people to say, “I’m sorry I can’t help bury our uncle,” or “I’m sorry I can’t clean up the mess of our niece or my sister in another house, but it’s the law.”
That was something that changed me: seeing the ambivalence, the doubt and the relief all in the same household.
The unequal toll of COVID in the US
How do you explain the fact that Black Americans and other people of color are falling sick and dying at much higher rates than whites?
Farmer: There’s nothing genetic or essential about this. This is social. And that’s good, because if it’s social, that means it’s in humans’ hands, not God’s hands. I think that lends (itself) to a kind of optimism.
I understand if African Americans, Latinos, the Navajo, I understand if they’re not optimistic about this. Why should they be? They have ample historical reason not to be optimistic. But it does mean it’s not carved in stone. I am convinced that we can bring this to heel. We will bring it to heel.
Deadly discrimination:America’s history of racism was a preexisting condition for COVID-19
How would you compare the COVID-19 experience in the U.S. with that of other countries?
Farmer: We’ve clearly done very poorly compared to peer nations – meaning, other rich, industrialized nations. But we’ve done very poorly compared to Rwanda. We can draw on those lessons. Why shouldn’t we?
Do you think Americans can overcome the lack of trust and nihilism you describe?
Farmer: We have no choice but to try. We’re not going to succeed by demonizing huge segments of the population. That too was the case in Rwanda. By some estimates, up to 15% of men who were called Hutu were involved in direct execution of orders to kill.
That’s worse than what we’re facing. It was a decades-long buildup and explosion and much shorter rapid dismantling of structural violence. It was a deeply moving thing to see.
What’s wrong with contact tracing in the US
Partners in Health provides contact tracing services, identifying people who may have been exposed, encouraging them to stay home so they don’t get others sick, and connecting them to resources to get food and pay rent. But so far, contact tracing hasn’t worked well in the United States. Why?
Farmer: Contact tracing (has to be) linked to a real commitment to social support. If we can’t think about the needs of those who are being called to isolate themselves, if we don’t tend to their everyday needs for food, shelter (and) pay their rent and cell phone bills, we’re not going to have good contact tracing.
That sounds pretty idealistic: that we’re going to provide enough support for vast numbers of people to stay home, away from work and families long enough to bring the epidemic under control.
Farmer: The thing about idealism, is if you can always link it to pragmatism, you’re going to be OK.
I think there’s nothing more pragmatic than trying to stand up a 1,200-person team to do contact tracing in eastern Massachusetts (as Partners in Health has done). Infusing that pragmatism with idealism is probably what’s going to turn the epidemic around in the United States.
Ebola outbreak offers reason for hope
It seems like you were very personally affected by the Ebola survivors you met and the stories they told.
Farmer: It was very hard. It’s always hard to see young people wither away like that or hear about people like some of these folks who lost their parents, children and spouses. It was just very hard.
Do you keep in touch with many of them?
Farmer: That’s one of the reasons (I’m) optimistic. We’ve seen these devastated families and devastated individuals – we’ve seen them get better. That squares with my experience everywhere in the world. Usually our patients get better.
This interview has been edited for length and clarity.
Contact Karen Weintraub at firstname.lastname@example.org.
Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input