“What happens to the poor is never separate from the actions of the powerful,” Paul Farmer wrote in his 2005 book. Pathologies of power. A physician, medical anthropologist and activist, Farmer has dedicated his life to championing health equity. As co-founder of Partners In Health (PIH), a nonprofit organization that provides free medical care in low-income countries, including Haiti, Peru and Rwanda, he has used the group’s findings to change global guidelines on how to treat TB and HIV. During the COVID-19 pandemic, Farmer and colleagues exposed vaccine monopolies that help explain why fewer than 10% of people have been fully immunized in low-income countries (P. Erfani et al. BMJ 374, n1837; 2021). Farmer treated patients until his death in Rwanda at the age of 62.
In 1990, he earned a doctorate in anthropology as well as an MD from Harvard Medical School in Boston, Massachusetts, where he later taught global health and social medicine. His opinions were shaped by his own experiences as a child in the United States and as a young adult in Haiti. They were deepened by his knowledge of social theory, political theory and the Catholic philosophy of “liberation theology”. This study focused its reflection on the systemic oppression of the poor.
Farmer’s 12 books and over 200 manuscripts reveal the principles that guided his actions. The money to save lives exists if lives are of equal value, Farmer argued. He criticized the public health field for the cost-effectiveness analyzes used by governments and donors to calculate when medical technologies they take for granted are worth it for those who cannot afford them themselves. In an editorial of Bulletin of the World Health Organization in 2003 he criticized members of the public health community who pushed for HIV prevention rather than care in poor countries because it was cheaper (P. Farmer Taurus. World health organ. 81, 699; 2003). At the time, HIV drugs were astronomically expensive, but there was no need, as he pointed out. Two years later, policy changes allowed generics to enter the market and prices fell drastically.
To achieve his vision of a world in which everyone has access to health care, Farmer has sometimes bent the rules. At the start of PIH in the 1990s, he and his co-founder Jim Yong Kim smuggled some US$92,000 worth of second-line tuberculosis drugs from Brigham and Women’s Hospital in Boston, Massachusetts, where they worked. both, to their patients in Peru, according to a profile in the new yorker. (A PIH donor later reimbursed the hospital for the drugs.) Years later, Farmer and Kim lent their support to an ambitious World Health Organization initiative to treat three million people with HIV. /AIDS by 2005. They realized that donors prefer to fund programs that focus narrowly on a single disease, rather than health care in general.
Privately, however, they wanted to restructure the systems, says Farmer’s close colleague, Adia Benton, an anthropologist at Northwestern University in Evanston, Illinois. “They knew that to get so many people into HIV care, you would have to change patent law, you would have to change manufacturing, you would have to build obstetrician-gynecologist clinics. He would say you can’t deal with mother-to-child transmission without good prenatal care,” she explains. “They were hustlers.”
PIH differs from most other humanitarian organizations in that it tries not only to build clinics, but also to ensure that they remain sustainable by operating within government-run services and enlisting staff locally at all levels. “I am a living testimony to that,” says Bailor Barrie, executive director of PIH Sierra Leone, a subsidiary created during the Ebola outbreak in 2014. Farmer and Barrie met when the latter was a global health student in the Farmer class at Harvard. Medicine School. “He is my teacher, my mentor, my colleague, my friend. I call him Pa because he’s like a father,” Barrie says. “I’m devastated.”
Farmer encouraged scientists who study disease to consider forces such as racism, sexism and poverty that impede people’s ability to benefit from the fruits of science. Although eradicating the sources of oppression is a difficult task, Farmer described how medical programs could work better if they aimed for equity (JS Mukherjee et al. Lancet Glob. Health 7, E410–E411; 2019). In this article, he wrote about how 100% of people who received small monthly stipends and food alongside his team’s free TB treatment in Peru were cured of the disease, compared to only 56% of those who received the drugs alone.
Benton suggests that Farmer’s political orientation stemmed from his experience growing up in relative poverty: one of six children, he lived in a bus, a boat, and a tent. His medical treatment for a broken leg as a graduate student in 1988 cost about double his mother’s annual salary as a cashier, he once wrote in the London book review. He explained that most of his bill was covered by Harvard medical insurance, while these health costs impoverish some 30 million households each year worldwide – if people receive treatment. “Three of PIH’s Haitian founders, all in their twenties, had recently died stupid deaths,” he wrote, of the preventable and easily treatable illnesses of sepsis, malaria and typhoid fever.
Farmer has spent his career trying to convince people that health care is a human right. For this, he became a celebrity in the spheres of global health. He leaves a legacy of researchers determined to pursue his mission. “He wasn’t just a guy with a vision,” Benton said. “He was brilliant.”
The author declares no competing interests.