Dr. Paul Farmer and Google.org: “Ebola: Beyond the Headlines” | Talks at Google

By | August 29, 2019


JACQUELINE FULLER: OK,
well, welcome, everybody. I’m Jacqueline Fuller. I lead google.org. It’s Google’s
philanthropy, focused on catalyzing the
best tech solutions around the world for humanity. And today, we have Doctor Paul
Farmer in the house. [CHEERING] PAUL FARMER: Oh, thanks. Nerd fest. JACQUELINE FULLER: Yes. Yes. So this is such a thrill
for so many of us. In fact, as we were
getting the word out, we had so many people
who were interested, Doctor Farmer, that we’ve got
people from Google offices in 41 different locations
around the world. We’ve got Germany, New York
City, Brazil, Mexico, Austin. Everyone wants to
hear from you today. So we’re so, so very
grateful that you’ve come. And so the flow that
we’re going to have is we will have conversation
and discussion for about 20 minutes. We’re going to then open
it up for live questions, so get your questions ready. And if you’re in one of
our offices, off location, we also have a Dory. You can find it. Just go Paul Farmer, if you
want to submit Dory questions, because we’ll want to take
all of your questions. PAUL FARMER: I’m having
that tattooed on my arm. JACQUELINE FULLER:
Go, Paul Farmer. So let me start by just giving
a little bit of an introduction for the man who needs
no introduction. Doctor Paul Farmer is a
medical anthropologist. He’s a physician. He’s also an expert in
infectious disease, which makes him the spot
on guy we want to have for our
discussion today, which is going to focus, in large
part, on the ebola epidemic. He’s one of the founders
of Partners in Health along with Jim Kim,
who’s now at WHO. PAUL FARMER: World Bank. JACQUELINE FULLER: Oh, sorry. World Bank. PAUL FARMER: Makes
a big difference. They’re the ones with the money. JACQUELINE FULLER: 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: That goes
direct to NSA here. JACQUELINE FULLER:
[LAUGHING] 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 Doctor Farmer and heard of him because he’s
the subject of Tracy Kidder’s biography, “Mountains Beyond
Mountains: The Quest of Doctor 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: Raise
your hand if you’ve read “Women, Poverty, and AIDS.” Thanks loads. JACQUELINE FULLER: 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: Raise your hands
if “Women, Poverty, and AIDS.” JACQUELINE FULLER:
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: 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– JACQUELINE 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,
human or nonhuman, are not the host, right? We’re accidental hosts. And so there’s a
lot of speculation that 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? That’s one thing. And there are other ways
it could 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 present very often in what’s called
hypovolemic shock. 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. It’s a disease of caregivers. Not just doctors–
nurses, nurses’ aides, but who does the
majority of caregiving? JACQUELINE 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. JACQUELINE FULLER: OK. 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 took down the health system–
in Sierra Leone and in Liberia. JACQUELINE 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. Doctor 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. JACQUELINE 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 of confirmed 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 their [INAUDIBLE]
of fever here? And because I knew it’s the same
forest 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. JACQUELINE FULLER: Yeah. PAUL FARMER: 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. JACQUELINE 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. JACQUELINE 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. JACQUELINE FULLER: Right. PAUL FARMER: Because air travel,
ports, cross border trade, and tourism. JACQUELINE FULLER: Decimated. Yeah. PAUL FARMER: They’ve
already badly affected. JACQUELINE FULLER: Center
for Global Developments 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. JACQUELINE FULLER: Yes. PAUL FARMER: And that
doesn’t always happen. JACQUELINE 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, OK, 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 Friedan. 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. JACQUELINE 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. JACQUELINE FULLER: OK. 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, [INAUDIBLE] 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 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 [INAUDIBLE] 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. JACQUELINE 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. JACQUELINE 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
[INAUDIBLE], 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? One box 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? Well, first of all, those sound
like 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, Doctor 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 Well Body Alliance works, or
Last Mile Health, or Partners in Health’s other
sister organization in Haiti that’s [INAUDIBLE],
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 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 [INAUDIBLE] 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. JACQUELINE 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. JACQUELINE 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– JACQUELINE FULLER: Yeah. Questions? No, just kidding. PAUL FARMER: OK, 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. JACQUELINE 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 we were 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. JACQUELINE 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. JACQUELINE FULLER:
We’ll take them. PAUL FARMER: Yeah. We’ll take them. JACQUELINE FULLER: 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. JACQUELINE 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 driven 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. JACQUELINE FULLER: Like
Partners in Health. PAUL FARMER: Like
Partners in Health. I mean, we’re proud
to be part of that. JACQUELINE FULLER:
Badge donate in back. PAUL FARMER: 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? JACQUELINE 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. JACQUELINE FULLER:
And gives hope to everyone else observing them. PAUL FARMER: That they can
be part of the solution. JACQUELINE 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, OK, 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. JACQUELINE 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. AUDIENCE: 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. JACQUELINE 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. JACQUELINE FULLER:
What’s the hashtag? AUDIENCE: [INAUDIBLE]. [INTERPOSING VOICES] PAUL FARMER: I like that. What’s a hashtag again? JACQUELINE FULLER: Oh my– PAUL FARMER: No, I have
a teenage daughter. She explained it to me. JACQUELINE FULLER: We’re gonna
do a little session afterwards. PAUL FARMER: I’m not done. I’m just getting warmed up. JACQUELINE FULLER: OK,
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. JACQUELINE FULLER: 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. JACQUELINE 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. JACQUELINE FULLER: All right,
we got another question. AUDIENCE: Hey. 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. JACQUELINE FULLER:
Did you really ask him to quote [INAUDIBLE]? 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, OK, 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, and 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. AUDIENCE: Do you have a
book you could recommend or books about the
kind of [INAUDIBLE]? PAUL FARMER: “Women,
Poverty, and AIDS,” for sure. Say again? 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 do. I’ll write some down for you. JACQUELINE 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. JACQUELINE 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 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. JACQUELINE FULLER: OK. Let’s take another
live question. 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. JACQUELINE FULLER: OK,
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– JACQUELINE FULLER: Yeah. We’ve got to get
to our nap pods. No, I’m just kidding. [LAUGHING] JACQUELINE FULLER:
We’re going to actually have more time after
this with Doctor Farmer and technologists,
because we specifically want to spend some
time with engineers. So if your 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. [INTERPOSING VOICES] JACQUELINE FULLER:
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. JACQUELINE FULLER: Yeah. 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. JACQUELINE FULLER: OK. Next question? 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? AUDIENCE: Your
review or the book? PAUL FARMER: My review. “Women, Poverty, and AIDS.” [LAUGHTER] PAUL FARMER: Sorry. 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. Against, [INAUDIBLE]
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. JACQUELINE 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
[INAUDIBLE] take off. 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, OK,
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 the 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. JACQUELINE FULLER:
OK, last question. PAUL FARMER: Great question. AUDIENCE: I have a couple
of questions on the– JACQUELINE FULLER: No,
you get one question. 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? JACQUELINE FULLER:
That’s a good question. PAUL FARMER: Two good questions. He was right. JACQUELINE 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 its 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– JACQUELINE 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 [INAUDIBLE] 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. JACQUELINE FULLER: So a
very important message from Doctor 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. JACQUELINE FULLER: Yeah. So let’s all thank Doctor
Farmer for coming here today, and his message for all of us. PAUL FARMER: Thank
you very much. Thank you. JACQUELINE FULLER: [INAUDIBLE]. PAUL FARMER: Thank you
so much for having me. JACQUELINE FULLER: Thank you. Thank you. Our hero.

9 thoughts on “Dr. Paul Farmer and Google.org: “Ebola: Beyond the Headlines” | Talks at Google

  1. Sebastian Schulz Post author

    Is there any chance to get Dr. Paul Farmer's books on Google Play store some time in the future? (region: europe, germany)

    Reply
  2. Theresa Muschiatti Post author

    Can this be interpreted in American sign language?  Captions are not so good.

    Reply
  3. Andrés Valencia Post author

    Thanks for the video and great information!!!

    I think Google.org could also helped with robots. According to the Wall Street a caring unit for ebola would need: 6.600 gallons of water, 2.500 gallons of bleach, 1.050 rubber gloves and 350 body suits.

    A robot would be perfect to disinfecting ebola and cleanning rooms.

    http://graphics.wsj.com/treating-ebola-by-the-numbers/?mod=e2tw

    Reply
  4. Bil Danielson Post author

    Thank you Google.org for hosting Dr Farmer! 

    Accessing this short talk helps a great deal to add to one's own personal knowledge. Where that dovetails is anyone's guess, but it certainly will not be an impediment to improving the situation regarding the "staff, stuff, space, and systems" addressed by Dr Farmer as key factors for success.  

    One thing I wish he would have touched upon is access to cheap, reliable, and abundant sources of energy in those parts of the world most at risk (the last mile). 

    Reply
  5. Craig Talbert Post author

    The "upstream vs downstream" distinction at 50:59 is profound. Thanks @Partners In Health! 

    Reply
  6. Hugo Campos Post author

    Thank you Dr. Farmer. And thanks Googlers for sharing this talk.

    Reply
  7. Jasdne R Post author

    The staffing, of all levels, in hospitals in England need more training from professionals that have specific and key training rather than passing on a watered-down, inaccurate version of information they've received in an email… Healthcare workers readily assume ebola but are misguided by their lack of knowledge, thinking every country in Africa is affected as they don't know what countries constitute west Africa. You're geographical knowledge doesn't have to be pristine since Google will tell you very rapidly that Botswana is in south Africa. Trouble is, very few labs are prepared for receiving and handling ebola contaminated samples, which is worrying if prompt and successful diagnosis will provide grounds to isolate infected patients and thus contain the situation.

    Reply

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