Ophelia Dahl and Paul Farmer

FRANK BLAKE: Ophelia and Paul, welcome to today's show.

OPHELIA DAHL: Thank you very much. It's good to be here.

PAUL FARMER: Terrific to be here. Thank you, Frank.

FRANK BLAKE: Let me start by asking you to take our listeners on your journey as founders of Partners In Health. What started you on the path, and when did you realize it was a path you were committed to?

OPHELIA DAHL: We met in 1983, and I had gone there to volunteer when I was 18, and wanted to see a different part of the world, and wanted to buy some time. Not quite knowing what I wanted to do, and I had been there for just a few months when I met Paul.

It was an instant click, instant soulmate kind of situation. We started a conversation, and really, that same day that went well, well into the night, and early morning, and I would say that it's really a conversation we've had ever since, and the conversation has just brought more and more people into it.

I think that the sense of going to a place that rearranges the way that you think about the world, or the way that you had thought the world was, it's an important moment for anyone. I think the difference was, for me, that I was introduced to Paul and a group of people, and it felt as though I wanted to just apply myself in my way. To be connected to those people, and to do work together.

PAUL FARMER: That's pretty much it for me as well. I hadn't-

OPHELIA DAHL: You had more of a plan, I think it's fair to say. When I talked to you about what we could do, about the work, you were 23, and you said if we do these things first, and then these things. I think vision is a good thing.

PAUL FARMER: Well, I had five years on you. I hadn't started medical school, and that year or so in Haiti was utterly transformational. I was ready to be transformed. I had grown up in rural Florida. The province of the healthy, and from a big family. We didn't think about healthcare delivery, or health insurance, and I knew I wanted to be a doctor. I'm not sure I knew why, but that year, in between college and medical school, changed me profoundly.

FRANK BLAKE: I suspect though, that a lot of people might start medical school thinking I'm going to use this for a deeper purpose, and greater good, or spend, as in your case Ophelia, spend a year, or some time in a country like Haiti, but then return to a more well-trodden path. What do you think was it that kept you on the path, that made the path so compelling, that you committed to it, or was that something embedded in yourselves from the start?

PAUL FARMER: I, as a medical professor now, as opposed to a medical student, I'm quite struck by how many medical students come in with those convictions, but I'm also struck by how many are able to sustain those convictions over time. I think that it's a different narrative than saying young people come into medical school, nursing school, or whatever, with a lot of convictions, and then they dissipate over time.

That really has not been my experience, whether teaching medical students and nursing students here, or in Haiti, or in Rwanda. It's how do you build a community, to keep those convictions alive? The conviction I'm referring to is wanting to do something meaningful and good for others. In this case, particular people who are ill or injured, so I think there's a lot, but I don't know that we were particularly exceptional.

OPHELIA DAHL: Yeah, I agree with that. I agree with that Frank, but I also think, as someone who didn't go to medical school, that there's the staying with it, and we think about this. Not because we think about leaving, but as Paul once said to me, or answered a question of someone who said how do you stay in this? Paul said, "you don't leave."

It's really something I turn to all the time, and obviously, you can apply it to all kinds of other facets of life, but I think that the idea, there are a couple of ingredients, right? The idea that you go somewhere as an 18-year-old, and you go there to see and learn, and you feel lucky to make friends, but then when there's a suggestion that you can do something to affect some change, even in a small way, you have to have been socialized to feel as though you can do something like that, which is obviously something we've all been socialized for.

A level of success and that means just bringing a kind of an attitude, really, of can do. It doesn't mean plowing through, and saying I know the answers, obviously, but it does mean saying, when someone says we need to raise money, it's like I think I can do that, or we need to fix, or find a set of supplies. I think I can do that, and then when you have some incremental, and usually, certainly at the beginning relatively small successes in this as a team. It's pretty infectious to feel as though you, and so I think if you only face barrier after barrier, it's probably a little bit more difficult to stay in the game, but that's another reason to do it with people you trust, and love, and like working with, because as you get tired, or you get dispirited, then people lift you up, so I think there are all kinds of ingredients that go into this.

FRANK BLAKE: There's a great quote, and I think I've got this right from you, Ophelia. The quote goes something like imagination allows you to make the link between the near of your lives with the distant others, and listening to you, I'm suspecting that there are pivotal stories, or stories, people that had an impact on you, that help you to sustain that optimism. Who are some of those people, or what are some of those stories?

OPHELIA DAHL: I go back to the time when I first went to Haiti, and I spent the first few months actually, really, I lived at a school for handicapped children, and in the city. In Port-au-Prince, and then I would go out on these outreach trips. So I truly was just listening, and watching, and thinking about how things could be different. I feel as though I got to know people in a much deeper way, and understand the history, and the sociopolitical economy of the region. I can remember the name of someone that I haven't spoken to, or heard from, which is unusual because we're in touch, but he was already an older man. I'm thinking about a guy who was, at that point, an older man. Probably not as old as I thought he was, because people who've lived a really hard life look a lot older than they are. 40-year-olds look a lot like 75-year-olds in those circumstances, but we sat down, and talked to him, and he told, and recounted this story of losing his land in the '50s, and having to choose, because they heard — well, they heard and saw that a dam was being built.

They heard their land was going to be flooded. They were thinking, "How are they going to flood the land? I've got my house here. I've got my land here, I've got my fields and crops." And sure enough, he told us, the day that they started to flood his livelihood, and ran up the mountainside, and decide whether to choose to carry a pig, or a goat, and charging up the hillside with his kids. Those are the kinds of stories that are a tremendously powerful foundation.

PAUL FARMER: Well, this is a particular place, Frank. It was a squatter settlement, that was established, really, because the valley was flooded, but when we went there it was a long time after that event, but people carried these memories of having known something better.

Some of the young people we worked with, the gentleman that Ophelia mentioned has passed on, but at least he survived to a ripe old age. We also worked with people who were more or less our own age, and three of them who were working with us died before their 30th birthday, and I can say that those were my first real experiences with grief and even death. Those were harrowing, and those stick with you, and in our case, because we were a community of folks that was growing because most were Haitian, there wasn't an option to say this is just so hard. Someone dies after childbirth. Someone dies of typhoid fever. Someone dies of cerebral malaria. Those were the three diagnoses in this case.

This is so hard. I would rather be shielded from it, and stop, but that's not an option for those who were living and working in their home country, and so this chance to convert those pretty harrowing losses into more conviction, and more effort, they were important to us.

OPHELIA DAHL: We have those kinds of big memories, and yet, of course, sifting through what it means, so, for me, when I think about certain specific memories, I think about, for example, a place. Not the original place where we were in Haiti, but a commune close by, where there was a clinic, and early on we realized that it wasn't going to be enough for us to build a clinic simply, or simply even be involved in training community health workers, if we didn't also have some of the responses to the questions asked by the community, and the patients. Like needing new houses, or needing to send their kids to school. The ever-present chant of people living on the margins, and I think that was an early lesson for me, in terms of making sure, and this is something I learned from being side by side with Paul, and my Haitian mentors. That you can't apply a different set of standards, and that's where the complexity stuff comes in, in terms of people who say "stick to your knitting," or don't get out of your lane, or mission creep, or any of those kinds of things, and, actually, that was when the work became even more enriching.

The example that came flashing to mind was working with a group of Haitian doctors and nurses in this commune. There was, there still is a river there, and at certain times of the year the river would become swirling, and fierce, so fierce that you couldn't cross it, and so there were people trapped on the other side, and there were women, really, literally, dying in childbirth, and we work with American doctors. One of those American doctors, Louise Ivers, who's here in Boston, and worked in Haiti for a long time, still does, got together, and said, "What do we need to combat this?" We'd already built ORs on the other side of the river. We need to get a bridge, and I remember a colleague saying to me you'll never get that bridge built, and it actually took six years, but it wasn't because we were able to buy a bridge. It was because of this extraordinary partnership thing that has to happen, including engineers from the university in the U.S., including the departments of transportation, including the army, the U.N.

PAUL FARMER: The Brazilians, I think, gave us a bridge.

OPHELIA DAHL: The Brazilians, and it was a bailey bridge, but these are the moments where you say of course it's not going to be a straight line, and of course it's going to be complicated. It makes you tired, but it makes you tired in a very good way, in a lucky way.

FRANK BLAKE: That's such a brilliant example, and the phrase I hear about both of you is that you pay reverent attention to others, and what they need, and that last part, what they need, is just exactly what you're talking about. That takes you into lots of different spaces.

PAUL FARMER: It's not as if the folks on either side of that river were ineloquent, or hesitating about the obvious. They said, "We need a damn bridge," and it was others who would say, "Stick to your knitting." Is that British, or English?

FRANK BLAKE: "I don't do bridges."

PAUL FARMER: I don't do bridges, and Ophelia, I would just add that the doctor you mentioned is Irish because she would correct you if she were here, but she's here at Harvard and has worked with Partners In Health for a long time. We're lucky that we have colleagues, in this case, in Haiti, and elsewhere, who would not say that's a ridiculous idea. In fact, as far as we could tell, the only way to get over a swollen river is with a bridge, I guess, or a raft. I couldn't imagine crossing that in a raft, and that was the right answer.

Haiti got hit by a number of hurricanes, major tropical storms, just before the earthquake, as you know Frank, and by that time we had other connections too. For example, the Prime Minister of Haiti, she's there. She's in the middle of all of her emergencies, and including political emergencies. I remember her emailing us, or texting, and saying I'm going to get that bridge out of that storage, so it took a long time, and a number of emergencies, and, unfortunately, we mustn't forget, a number of people died, because they really couldn't reach medical services, but, in the end, you also have to be able to close your ears to this chorus of complaint, and criticism. This is mission creep, or whatever. It wasn't mission creep, in the eyes of our friends and colleagues, and it wasn't mission creep in the eyes of those who needed access to medical services, and so you had to ask in whose eyes is this an example of mission creep?

FRANK BLAKE: One of the descriptions you provide of Partners In Health is we go, we make house calls, we build health systems, we stay, which strikes me as such a very clear, concise statement that packs a lot, and I suspect within it there's a lot of differentiation, in terms of your approach from others. Can you go through what's embedded in those seemingly straightforward concepts?

PAUL FARMER: It takes a long time to make a difference, really, with any pressing social problem. At least I can't think of an exception to that, whether we're talking about health disparities, or climate change, or opening up say American universities to everyone who would be, want to study and be good. Those are decades-long endeavors, so the "We go, We stay" meaning we're not going to go somewhere and just declare mission accomplished, without having done that mission, and we've described that, as have many others, not original, as accompaniment. We're walking with people. Not pushing them, or trying to lead them.

The "We make house calls" part is also a nod to our colleagues, community health workers, and families because the majority of caregiving in the world is afforded by families. Your immediate family, and for someone with any chronic illness to have to schlep into a big teaching hospital, or a big hospital of any sort, in order to get something that really ought to be made available closer to home. This is one of the big pathologies of the U.S. healthcare system, and where did we learn that? In Haiti, and in Rwanda, and in Malawi, so that slogan, I still think it's pretty solid. It doesn't describe all of what we do, because we're interested in teaching and learning, but that was the idea behind that. I don't know. Ophelia, was that acceptable?

OPHELIA DAHL: I think it makes total sense, and I agree. In some ways, that, I was going to say slogan, for want of a better word, but it's not a slogan. I think it's much deeper, but in some ways, it's indirectly proportional to our mission statement, which is meatier, but really, is saying a very similar thing. The "We stay" part is really, obviously, another way of saying we don't leave, and it's not that we refuse to leave, or will, any of that. It's really that we will be here for as long as you want us to be here. Not when a grant runs out.

PAUL FARMER: Yes, exactly. It's not that project mentality. The other point, which I'm sure, Frank, that you've already gathered, is that if Partners In Health is a confederation of sister organizations, with a Haitian branch, and a Rwandan branch, Navajo affiliate, then why would they have an exit plan? They're from there, so 99% of our team in Haiti is Haitian, if it's not more, towards 100%. I would just say one other thing, with a nod to our friend Jim Kim, who always reminded us, and as we heard in Peru, and Mexico, and Haiti, is people don't want to live in poverty, so the big picture intervention is to get rid of poverty, and that requires a series of interventions that are not going to happen largely within hospital walls, and he's been particularly committed to that. Not just in recent decades, but since we were students, and first started this endeavor.

FRANK BLAKE: Given all, Partners In Health has expanded so dramatically. It makes such an impact now, serving, as I said at the start, around four million people. With so many needs worldwide, how do you decide to go where you're going next? What's in the future for Partners In Health?

OPHELIA DAHL: Well, I have to say that's an exciting question for us, and I'm smiling, because on the one hand it's true, and I was thinking, actually, with that statement, about we go. We are a collective of colleagues now, around about 16,000 people altogether, and yet, in a relatively small number of countries, which is the point. We heard for many years, well, you can do that it in Haiti, because of X, Y, and Z, and then we started working in Peru. Well, you can do this or that in Peru, because it's Peru, and it didn't really matter how many countries PIH was working in concert with the governments, local and national level. It didn't matter. People would still say yes, but you can't do it here, and have you tried to do it there?

There's actually less of that these days, and there's much more of would you come here, or there? One of the things that we've been working on now, for the last few years, and again, with our original colleagues from Haiti. When we went to Rwanda, when we were invited to Rwanda in 2005, it was with our Haitian colleagues, who had the most experience, in terms of treating HIV, and in building a health system, and in training community health works, and in the supply chain, so they were the experts. Now, we have been working over the last few years to build the University of Global Health Equity in northern Rwanda, as a first step in the north. There's going to be more than one campus, and it has graduated to master's classes in global health and has just admitted its first medical school class, and these answers, and I'm not an academic, but I am so excited at the idea of it's not just a medical school.

It is a university that applies itself to the entire field of global health equity, of lessening that enormous gap, and that means supply chain, and that means everything that is needed in this. All of these important components, that allow people, and that might mean at some point infrastructure, and all of it, so that is at least one of them, I don't even want to say answer, because I think it's much bigger than that, by saying it's an answer to the question of how are you everywhere? I do think it's one of the answers to it.

PAUL FARMER: Inside an institution like that, or institutions like that, universities, medical schools, nursing schools, there are also serious equity issues, so I know that in this first medical school class. Their goal was to have at least 70% of the first medical school classes to be women, and they will have no trouble meeting that goal since they had thousands of applications within short order. People are drawn to not only the higher education but the idea of fairness, justice, equity.

FRANK BLAKE: All right. In closing, I have two very general questions. First: If you could change one thing about how things work, what would it be?

OPHELIA DAHL: We've been able to accomplish a lot, but I am still, we are having the same conversations at the board level, and amongst ourselves, and with a general audience, about the fact that we don't have enough resources to do what we really want to do, and I think we have loads of generous people, who've jumped into this work in extraordinary ways. Yet, we know that there are enough resources out there to tackle these enormous problems, and I would say that a frustration for me, I'll never stop looking for support in all kinds of different ways, but I still feel like the dreaming big, and one of the things, Frank, at the very beginning, when you were talking about Paul's qualifications, and titles, and things. One of the things that you left off was that he's the chief strategist for Partners In Health, and in order to be-

PAUL FARMER: It's a groovy term. I love it.

OPHELIA DAHL: It is a groovy term. We turn to it all the time. If you have a chief strategist, then you want the strategist to be able to strategize in a visionary way, and you want to be able to make sure that ability to even, I'd go so far as to say see around corners, and to see what's next. Look at the ways that we've been able to turn relatively small amounts of money into enormous policy changes, and to just up the way people think that things can be done, and what can be achieved together, and I think that's what I'd like to change. Is that we all be allowed to dream as big as we need to, without worrying about the bottom line.

PAUL FARMER: For once, I may succeed in being more pithy than Ophelia, so a failure of imagination is the most frustrating thing, and that failure, it tends to be on behalf of other people. It's not like we can't imagine our own kids going to university, or we can't imagine having safe shelter, or can't imagine being spared a plague for ourselves, and our families, so why can't we imagine that for other people who've been shut out of material modernity, or being in some other ways punished by where they were born, or who they were? That failure of imagination for other people's aspirations, that's the big one for me too.

FRANK BLAKE: All right … I have a final question. It's a bit of a meandering question, so bear with me.

OPHELIA DAHL: It's okay. It's perfect for us.

PAUL FARMER: We're specialists.

FRANK BLAKE: Paul has described you as exquisitely sensitive to other people's suffering and getting physically anguished about it, and you've described yourself as unfailingly optimistic, and said that optimism is the only choice, if we're to transcend apathy, and then I think if optimism is a choice, that suggests that it requires work to maintain the outlook. What are some of the things you both do to maintain that optimism? Are there practices, books, people you turn to? How do you sustain optimism in the face of all that you see, and all the needs that you see that need to be met, and just the work in front of you?

PAUL FARMER: Well, in terms of the list you just gave Frank, for us, it's all of the above, and we mention other parts of that list. Friends, people we care about doing the same work, encouraging each other. For some, it's spiritual practice. It's thinking about what is the meaning of life on this beautiful, but uneven planet of ours? I would say just one thing, that I say to students, or others, or anybody who'll listen, and that is if you stick with something long enough, then one of the things that gives you optimism is remembering what you saw before, and seeing that it's addressed. Just going back to a couple of the examples that we gave, in 1983, it was obvious to us that there needed to be a facility that could take care of complex illness and injury, and neither of us had gone beyond that. I hadn't gone to medical school, but it was obvious, and that was before you start losing people because they don't have access to a hospital, and then you go back there, as I am about to. There's a hospital. Well, that causes good cheer or Rwanda. Well, the Rwandans told us that you could read.

Why did the genocide happen? How could you possibly understand the genocide, if you didn't understand the exclusion of folks from healthcare, education, et cetera? You can't, I don't believe, and so just like in Haiti. They're like, "We would like to go to college ourselves," or, "Like to become," fill in the blank. Well, there is a university there now, and so, again, having recently been there, it's also a beautiful university, I might add, and Ophelia already mentioned, it's called the University of Global Health Equity. That's pretty straightforward, and it makes me remember, and makes other people remember, obviously, the Rwandan people, a terrible, terrible time, and to look around, say that's not what it looks like now. You don't feel insecure in Rwanda now. You don't feel like the government is going to go after you, and encourage people to do terrible things on the national radio station now, so whether you're looking at any of the places that we've mentioned, all of the places in which we work, you do see progress, and if you don't see it you need to look harder, you need to read harder, you need to reflect harder, you need to pray harder. At least that's been, I think, very helpful to us.

OPHELIA DAHL: I would say that there's no question that going, seeing progress, and at this point, there's such a focus, Frank, these days, on the relatively quick solution. There's a romanticization of an answer that will be fast, for, actually, to reverse systems that have sometimes taken centuries to undo, and I think that the eye on the longterm is very important. That doesn't mean being endlessly patient. It means finding the right balance of patience and impatience, and making sure that the kinds of changes that you are trying to implement are going to be longterm changes, and you're not going to be giving first aid, but they're in there. That's where the complexity comes in. We're thinking about systems and that kind of thing, but I would also say it's going, so you see the progress.

That obviously can keep you in the game for a long time. The other thing is to go where the work is, and we have been able to do that since we first set foot in Haiti. If I am ever feeling down about almost anything, and I visit my colleagues and friends, and the work at any one of the sites. I recently came back from Sierra Leone, and, as Paul said, you only have to think back 20 years, and imagine that place in the midst of a civil war, or Liberia, and then cast your mind back a few years ago to Ebola, and now to go there. It really is an antidote for despair, no question.

FRANK BLAKE: That's fantastic. Where would you suggest, for listeners who are interested in what you're doing, where would you point them? Your website, when is the documentary coming out on you, what's the best way for listeners to learn more about you?

OPHELIA DAHL: No question, it would be the website, which is pih.org, and there's loads of stuff on there about the work in different countries, how to get involved. The documentary has been released, and is available, will be made available. They are working on a deal right now, that it will become apparent when it's available, and as soon as it does, and is available for easy watching, then that will be on our website as well.

PAUL FARMER: I would just add, about that film: Obviously, we're not filmmakers. We didn't make it, and it's called Bending the Arc, if you hadn't said that. I don't know the details yet, about how it works, but many universities, students, I just went to a showing in Toronto with Partners In Health Canada. A lot of people there didn't know about Partners In Health, and that was one of the purposes of that meeting, but the people who made that film really looked hard for archival footage and worked hard on it. I think it's a very quick way for a deep dive.

OPHELIA DAHL: Spent 10 years actually making it altogether, and it was interrupted by the earthquake, but I think that one way and Paul is right to mention this if people were interested in doing a screening. I think, again, if someone was to send an email to info@pih.org, someone will respond to that, about the way to do that.

FRANK BLAKE: Terrific! Well, thank you so much for your time. It is absolutely clear why you're heroes to so many, and thank you for the difference you're making in this world.

• Partners in Health Website
• Bending the Arc Documentary
• Paul Farmer bio
• Ophelia Dahl bio
• The New Yorker: "Ophelia Dahl's National Health Service"