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Paul Farmer: “Accompaniment” as Policy

5.25.11

Paul Farmer

Paul Farmer

Photograph by Justin Ide/ Harvard News Office

On the afternoon before Commencement, the Harvard Kennedy School (HKS) gathers its imminent graduates in the John F. Kennedy Jr. Forum for a brief address by an individual who embodies some aspect of its public-service mission. Previous speakers have included New York Times columnist Nicholas Kristof ’82, Mexican president Felipe Calderón, M.P.A. ’00, and Liberian president Ellen Johnson Sirleaf, M.P.A. ’71, who will be the guest speaker at this year’s afternoon exercises in Harvard Yard. This year’s speaker was Kolokotrones University Professor Paul Farmer, M.D.-Ph.D. ’90, co-founder of Partners In Health, and perhaps none of his predecessors ever received so simple and devastating an introduction: HKS dean David Ellwood told the audience, “I am enormously proud of your hard work and your commitment and all that you have done and even more all that you will do. But no matter what you do, and no matter how hard you work, think about Paul Farmer as a model of someone that we can aim for.…I aspire for all of you, as I aspire for all of us, the chance to be Paul Farmer.”

An anthropologist and physician, Farmer chairs the department of global health and social medicine at Harvard Medical School (HMS) and is chief of the division of global health equity at Brigham and Women’s Hospital; his HMS CV notes that he and colleagues “in the U.S. and abroad have pioneered novel, community-based treatment strategies that demonstrate the delivery of high-quality health care in resource-poor settings.” Farmer also serves as UN Deputy Special Envoy for Haiti, under Special Envoy Bill Clinton. His earlier work with the rural poor in Haiti is the subject of the book Mountains Beyond Mountains, by Tracy Kidder ’67, and his own new book, Haiti after the Earthquake (PublicAffairs), will appear in July.

Speaking forcefully and rapidly, Farmer said he was especially grateful to be at the Kennedy School, where “governance and policy are the focus of your studies.” The past few years, he explained, have proved an object lesson for him on the difficulty of moving from the care of individual patients to building health systems in settings of privation and disarray, the very arena he thought he know most about. Instead, the 2010 earthquake in Haiti taught him “that we still do not possess the ability to translate goodwill and resources into robust responses to disasters natural and unnatural.”


 

“Accompaniment”—the response to this difficult lesson that Farmer chose to lay out for his HKS listeners—may have seemed slight at first glance, but grew more potent as he went on, citing in passing sources from the New Testament to Max Weber, Gustavo Gutierrez, Roberto Goizueta, and Malcolm Gladwell.

“To accompany someone,” he said, “is to go somewhere with him or her, to break bread together, to be present on a journey with a beginning and an end…There’s an element of mystery and openness….I’ll share your fate for awhile, and by ‘awhile’ I don’t mean ‘a little while.’ Accompaniment is much more often about sticking with a task until it’s deemed completed by the person or person being accompanied, rather than by the accompagnateur."

In every setting where PIH has worked, he said, there are people who need accompaniment: patients and poor families, but also public-health officials, clinicians—doctors, nurses, social workers—“without ready access to the tools of our trade,” teachers without notebooks, without even pencils. “In other words, even the erstwhile accompagnateurs need accompaniment. It doesn’t weaken this concept to note that everyone who draws breath needs accompaniment at some stage of life and that some need it more than others. Nor does it weaken the notion…when we acknowledge that its role in the formulation of policy and in policy implementation will vary from place to place and from time to time. There’s no ‘one size fits all.’ ”

What, he asked, does this have to do with governance and enlightened policy?

Great failures of policy and government, he noted, often occur because of failures during the implementation of projects, and such failures often arise from the tendency of many people to want to help the poor—but only from a controlled distance. He cited a Haitian example in which architects planned a new settlement for earthquake victims on a site they had never visited, which turned out to be in the middle of a flood plain. "Accompaniment," he suggested, can go a long way toward making sure that implementation does work.

The really costly failures, he added, often result from failures of the imagination. “Just because we cannot yet measure the value of accompaniment doesn’t mean it cannot serve as an important notion to guide us forward.” He warned his audience to “beware the iron cage of rationality” and confessed, “This was the long, hard lesson of the earthquake. We all wanted to be saved by expertise, but we never were.”

True accompaniment, on the other hand, “does not privilege technical expertise above solidarity or compassion or a willingness to tackle what may seem to be insuperable challenges,” Farmer declared. “It requires cooperation, openness, and teamwork…Much more can be accomplished looking forward with an open-source view of the world. Ideas for good governance, whether of organizations, or government bureaucracies, or corporations, are meant to be shared, and shared widely.”

“May the idea of accompaniment go with you on your own journeys wherever they may lead you,” he told the graduating students, “and God speed!”

 

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