Student Voices: Paul Farmer, An Engineer’s Catalyst into Global Health

We live in an age of data, numbers and cost-effectiveness created from models and formulas, where the uniqueness of communities, families and individuals is reduced to mere statistics, and human dignity is all but lost.

I am an engineer. I love numbers. I find clarity and understanding in numbers. Some would even say that numbers, not English, are my first language; however, numbers are just a piece of the puzzle. And when it comes to a right to live and breathe, numbers should only be that, a piece of the puzzle.

As a chemical and biological engineer who subspecialized in process engineering and sustainable systems development, I entered into

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the global health and international development spaces from an unusual path. When I left a promising engineering career in biotechnology five years ago, I lacked the coherent language to be able to wholly describe why. What was it that I had observed about systems in Eastern Africa that made me reconsider my professional choices?

My Aunt Pam helped me organize my thoughts by putting me onto Tracy Kidder’s book about Dr. Paul Farmer’s work, Mountains Beyond Mountains. His community-centered, patient-focused, sustainable systems approach to health gave form to the jumble of thoughts that I had been attempting to aggregate.

Farmer, a physician in infectious disease and a doctor of medical anthropology, has spent his career demanding better of society; demanding that we care for the individual, the family and the community in impoverished locales. These people have names, faces and lives that are worthy of human dignity, access to basic healthcare, and proven health methods. Farmer has shown himself to be a modern-day David in a battle against the Goliath of outdated, inferior global health norms in low-resource settings.

I had the honor to meet with Farmer when he visited Duke in February. I was given the exceptional opportunity to take part in a small graduate student meeting with Farmer, his talk in Page Auditorium and a private dinner for him afterwards.

A reoccurring theme emerged throughout the day; one that focused on global health equity from the perspective of existing, persistent issues in health development. How can we, as multi-disciplinary practitioners, start to change the lens of global health and adjust the balance to more holistically protect those who are most disenfranchised?

When talking on global health, Farmer combines candor, skepticism, and humor. He spoke poignantly on:

• The value of knowing the historical context of development and its role in dictating the management of current global health issues;
• The resulting and continued existence of “public health luddites,” their commitment to outdated treatment norms that call upon “colonialist recipes for treatment,” and the subsequent distrust and hostility towards health providers in poor communities as a result.
• And finally, the siloed nature of fields within both development and global health, despite an ever-growing, complex paradigm that urgently calls for interdisciplinary thought and cooperation.

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Even while candidly setting the stage on the existing state of affairs in global health, Dr. Farmer brought a sense of hope and confidence in the growth of a new type of thinking--something that he calls “pragmatic solidarity.” This idea recognizes that most people acknowledge the suffering of others, but pure solidarity, in and of itself, lacks the teeth to effect actual change. Solidarity is not enough; it is too abstract. Social justice requires pragmatic actions that lead to substantive health improvements and a reduction in structural violence. Farmer emphasized that the current health situation necessitates pragmatic solidarity in order to lead to substantive equality, health equity and a value on human dignity.

So, how do we practice pragmatic solidarity? Farmer underlined the importance of growing local capacity by empowering and upskilling community health workers to help with the management of chronic and non-communicable diseases. Nations can also reduce the detrimental effects of brain drain by incentivizing the return of citizens with better pay, reliable housing, and a sense of purpose and value within the system.

Sanford Professor Manoj Mohanan, the moderator for Farmer’s public talk, posed an excellent question regarding the opportunity to encourage the return of engineers and their integration into the health space. Maybe with fewer engineers leaving, doctors would be less necessary, he said.

I may be a bit partial on the matter, but I think that he is on to something. Should health systems just focus on health or should they be more comprehensive and inclusive? As a systems development specialist, I see transportation infrastructure, access to secondary and tertiary education, and energy self-sufficiency at the core of the challenges facing the global health space. Can we think bigger and outside of health in our definition of “health systems” in order to create more effective, sustainable solutions?

With a massive increase in connectivity and, arguably, the largest technological boom in history, we are at a turning point in global health. As technology pushes high-income countries further along the development scale, we can either continue to allow the gap between the rich and the poor to grow or we can rethink how we do global health. As Farmer says, accountability is mandatory and containment without care does not work. We must resist the false logic that the poor are too poor to justify comprehensive, effective healthcare.

Take a page out of Farmer’s book and you will see a path to these goals. We can redefine the meaning of the term “global health” in a way that reimagines its professions and includes the voice of the poor. The time is now to leave containment behind and pursue a better, more inclusive tomorrow by way of pragmatic solidarity.

Alix Michael received her BS in Chemical & Biological Engineering and minor in French at Tufts University. She worked for four years as a process engineer and process improvement specialist in large production facilities, alternative energies and biotechnology before starting at Duke in the fall of 2019.  She is pursuing a dual-degree with the Sanford School of Public Policy and Duke Global Health Institute, where she will receive a Master of International Development Policy and a Master of Science in Global Health.