PIH co-founder Paul Farmer reflects on aid, the importance of "accompaniment," and Haiti following the January 2010 earthquake. Read an excerpt of "Partners in Help: Assisting the Poor Over the Long Term" below, and check out the full article in Foreign Affairs


PIH co-founder Paul Farmer

The road from policy development to implementation is usually long and rocky, one that must be trod with companions. When travelers have diverged as dramatically as Haiti and the United States, communication between them becomes difficult. About ten years ago, one of my colleagues was examining a patient, a five-year-old girl named Maveline, and found a tumor in her abdomen. It turned out to be cancer on her right kidney, curable if removed before it spread elsewhere. That procedure, a nephrectomy, could be performed right there in rural Haiti — at one of the hospitals we built, an investment that had been regarded by some policy experts as foolish. The procedure went smoothly enough, but an X-ray suggested that the cancer had already spread to Maveline's lungs, and she needed chemotherapy and radiation, which could not be performed in Haiti. Since I was then living in a faculty apartment in a Harvard dorm but often absent, my wife and I thought that the child and her mother might stay there for a month or two while receiving treatment in Boston.

The two months or so turned into a year, and we got pretty close to Maveline and her family. When in Boston working at the Brigham and Women's Hospital, I would come home at about nine o'clock at night, tired but looking forward to seeing Maveline. Her mother, who had never before left central Haiti, would make me dinner, and we would all sit and watch cartoons or whatever Maveline wanted.

One night, well after nine, I was eating a home-cooked meal and sitting with Maveline and her mother, and there was a rap on the door. In came two students: one from Harvard and one from MIT. The Harvard student, Emilio, was from Miami, and although he had never once traveled to Haiti, he'd mastered Haitian Creole with a touching fluency that said a lot about him (he has since become a Jesuit priest and has dedicated himself to the poor in Haiti and Brazil). I'd never seen the MIT student before, but he was Haitian, and the conversation — completely in Creole — went something like this:

MIT student: "You're Dr. Paul Farmer?"

Me (suppressed thought): "No, I killed him and took his apartment."

Me (actual words): "Yes, nice to meet you."

MIT student: "You wrote The Uses of Haiti?"

Emilio, somewhat proudly: "Yes, and he's written other books as well."

Maveline's mother (hands on hips, mildly offended): "Dr. Paul, you never told me you knew how to read and write!"

I tell this story to amuse, sure, but also to illustrate how inequality works in the modern world and thus what an accompaniment approach needs to address. Maveline is still alive and well, but I'm not confident her mother knows how to read and write.

Haiti needs and deserves proper cancer and surgical care facilities and new and better health systems. But for this to happen, we will have to move from aid to accompaniment. Maveline needed an open-ended commitment; her care did not last for a couple of months but for years. An accompagnateur would not say, "Sorry, Maveline, we can help with your surgery but not your chemo." Seeing Maveline through to a cure involved a great many people. And her disease uncovered gaps in local infrastructure: If she'd been seen earlier and her tumor had been found before it spread to her lungs, much needless suffering could have been avoided. If her mother had been able to attend school, she would have been able to read and write, and chances are that Maveline would not have been born to poverty, and so on. It is not a bad thing to think systemically; if you want to solve problems, do not fear so-called mission creep. If the biggest failures in the policy world concern implementation or delivery, the second-biggest cause of failure is that programs are too often stovepiped, even though the problems they seek to address — health and illiteracy, for example — are tightly interwoven.

Read Paul Farmer's full article in Foreign Affairs.