Remembering Dr Paul Farmer: The Doctor to the Poorest

Paul Farmer’s name and his contribution to medicine and social justice may be unfamiliar to many in India, but his legacy looms large across the globe; his work more relevant than ever, including in India. Paul passed away on Monday, 21 February 2022, while working in Butaro, a mountain town in Rwanda, at the age of 62. His death is being deeply mourned by many including heads of states and other luminaries; his passing especially reverberating in the healthcare community. This loss feels very personal.Paul Farmer was an Infectious Disease doctor and an anthropologist. He was a Professor of Medicine at Harvard Medical School and Chief of the Division of Global Health at Brigham and Women’s Hospital in Boston.He was later conferred the title of University Professor, the rare and highest honor that Harvard reserves for its faculty. He co-founded a large global health care organization, called Partners in Health, along with Ophelia Dahl and Jim Yong Kim, focused on delivering high-quality care to the neediest in different regions of the world.Paul often spoke of the “privilege” of attending to the sick. However, he did not do so with a sense of charity. For him healing began with an understanding of the social and economic contexts in which diseases emerge and afflict.He critiqued modern medicine’s myopia in regarding sickness merely as biological phenomena. He always attempted to probe deeper into societal maladies that promote illnesses and suffering. In his teachings and writings, he would pose questions such as- Who becomes sick and why? Who has access to adequate services? How might inequities of risks and outcomes be assessed?Isolation, Panic, Trauma: Is Mental Health Aid Reaching The Poor? Paul authored 12 books and wrote over 200 scientific papers. But he was no armchair academic. He emphasized learning through practice and via the lived experience. His experiences as a visiting student volunteer in Cange, an impoverished village in the central plateau of Haiti, in the 1980s, were formative. Here he witnessed for the first time, the consequences of lop-sided development projects that pushed common people to the brink and helped fuel a health crisis that brought the country to its knees.Construction of a large dam in Cange at that time had displaced many, robbing them of their livelihoods and their homes.Ideologies about the sanctity of market were ascendant. Pressures from large international donors like the IMF and World Bank insisted that the country “divest” from healthcare and education sectors as a precondition for receiving financial aid. Whatever little safety net a country like Haiti could offer its citizens were abruptly snatched away. The healthcare impact of these measures were disastrous-lack of access to treatment or half-treatments fueled an epidemic of tuberculosis, especially multi-drug resistant TB (MDRTB) and AIDS. The latter two conditions were regarded as death sentences by the prevailing wisdom of healthcare experts. Organizations like WHO, preached a “pragmatic” approach, and lectured on “cost-effectiveness” and “sustainability”, to developing countries like Haiti.“The idea that some lives matter less is the root of all that is wrong with the world”, he would say.The question remained, “cost-effectiveness” and “sustainability” for whom? Paul wondered whether it was feasible to ask similar questions to patients in the developed world-we are withholding medicines from you because it is not “cost-effective” or “sustainable” to treat you? 'I Will Die Without Insulin' Why Cost is Driving Some to Ration ItThis institutionalized discrimination against the world’s poor galvanized Paul Farmer and his friend Jim Yong Kim (who later served as the President of the World Bank). They saved their meagre incomes as medical trainees to start a clinic in Cange, seeking shelter in a Boston church to save paying on their rent, while pursuing their training at Brigham and Women’s Hospital.The clinic started treating patients with MDRTB, using multiple antitubercular drugs. They sought and built community partnerships, where members of the community (“accompaniers”), would travel from village to village to ensure that the patients had food, water and were taking their pills regularly. The results were dramatic. Not only did the patients survive but they thrived once their diseases were cured.The Haiti model was later incorporated by the WHO (initially with much reluctance) and became a beacon for treating patients with MDRTB globally. It also informed subsequent responses to the AIDS epidemic, Ebola and more recently COVID-19. Partners-in-Health (PIH) became a global operation spanning countries like Peru, Russia, Lesotho, Malawi, Kazakhstan, Rwanda, Sierra Leone, Liberia, Navajo Nation and United States. The PIH model was similar everywhere: assess local context, build community partnerships, bring scientifically sound treatments to the table, and always treat patients with dignity and respect.This model demonstrated that it was very much possible to implement high quality medical care in diverse settings including to the most resource depleted and ravaged regions of the world.Sanofi-GSK COVID-19 Vaccine Seeks Regulatory Approval: What's the Efficacy?While Paul Farmer’s many accomplishments need no enumeration, it would be remiss not to mention his role and that of PIH during the COVID-19 pandemic. He was also a prominent voice that called on the Biden administration to stop blocking the emergency COVID-19 waiver of World Trade Organization intellectual property rights to make COVID vaccines available to all countries. Microbes, as he liked to say, move freely but compassions remain grounded.The Haiti model was later incorporated by the WHO (initially with much reluctance) and became a beacon for treating patients with MDRTB globally. It also informed subsequent responses to the AIDS epidemic, Ebola and more recently COVID-19. Partners-in-Health (PIH) became a global operation spanning countries like Peru, Russia, Lesotho, Malawi, Kazakhstan, Rwanda, Sierra Leone, Liberia, Navajo Nation and United States. The PIH model was similar everywhere: assess local context, build community partnerships, bring scientifically sound treatments to the table, and always treat patients with dignity and respect. This model demonstrated that it was very much possible to implement high quality medical care in diverse settings including to the most resource depleted and ravaged regions of the world.While Paul Farmer’s many accomplishments need no enumeration, it would be remiss not to mention his role and that of PIH during the COVID-19 pandemic. He was also a prominent voice that called on the Biden administration to stop blocking the emergency COVID-19 waiver of World Trade Organization intellectual property rights to make COVID vaccines available to all countries. Microbes, as he liked to say, move freely but compassions remain grounded.Joe Biden's Report Card: A Look at the US President’s First Year in OfficeTo elevate Paul to sainthood would be a misplaced tribute to this extraordinary individual. Paul developed many friends and won admirers in high places. Desmond Tutu once called Farmer "one of the great advocates for the poorest and sickest of our planet.”Bill Clinton in a statement after his passing said, “Paul Farmer changed the way health care is delivered in the most impoverished places on Earth. He saw every day as a new opportunity to teach, learn, give, and serve — and it was impossible to spend any time with him and not feel the same.” Books were written about him and he was a subject of a recent film. But he remained always accessible to his colleagues, students and trainees. He could be provocative, funny, mischievous but always affectionate.He emphasized the warmth of the clinical exchange, in theory and practice, as an antidote to the “experience-distant” approaches of modern medicine and socioeconomic development models. Not surprisingly, he had a special place in his heart for his patients. He often lived among the people he was treating. “Dokte` Paul” was also godfather to scores of children of his patients.Cynicism, he liked to say, “is a dead end.” For him, optimism was a moral imperative. He inspired a generation of doctors, nurses and other health care workers.And, I am are sure, through his works and example, he will continue to do so in the future.Doctors Without Borders: 50 Years of Humanity(The author, Dr Sandeep Kumar, is an Associate Professor of Neurology at Harvard Medical School, Boston.)

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Remembering Dr Paul Farmer: The Doctor to the Poorest

Dr. Farmer's work for the poor has created some of the most famous care models for those in developing countries

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