“I’M no prophet. My job is making windows where there were once walls,” said Michel Foucault, a maverick French philosopher of the second half of the last century.

Paul Farmer was one such man in the medical profession who made windows in the walls of healthcare for the voiceless and marginalised poor. I say medical profession, but he was not limited to it. This is about great thinkers and reformers; they cross the Rubicons of disciplines and intellectually position themselves at the crossroads of various knowledge streams. Paul Farmer was a medical doctor but also had a doctorate in medical anthropology. His life and work are a great example of the application of integrated knowledge to solve the problems of healthcare faced by poor people who cannot pay and hence are of no interest to the health market.

He broke the mould of ‘mainstream’ and went where healthcare was most needed and made a big difference.

Coming from a poor American family and the scion of a ‘free-spirited’ father who at one time housed his family of eight in a discarded school bus and at another time in a houseboat, Paul, the second of six siblings, focused on his studies. Despite their poverty, his parents exposed their children to good books of high literature. After winning a full scholarship to Duke University in Durham, Paul got interested in medical anthropology. Close to the university is where he got exposed to tobacco farm workers, some of whom were Haitian migrants. He got closer to them and was struck by their poverty and the misery of their living conditions. This marked the start of his lifelong Haiti project.

Paul Farmer broke the mould of ‘mainstream’ and went where healthcare was most needed.

He got into a joint medical and medical anthropology programme at Harvard University. During this time, he also travelled to Haiti for the first time. From the capital Port au Prince he travelled with a priest deep inside the country and ended up in Cange, a small haphazard settlement of people who had been displaced due to the construction of a dam. Stark poor and deprived of clean drinking water, with little food, no education and living in dirty huts, these people were also victims of rampant malaria, tuberculosis, typhoid and other communicable diseases. It was among the poorest and the sickest in Cange that Paul Farmer found his vocation, a calling that he fully responded to with a lifetime of healthcare development work.

He pursued his medical degree at Harvard and continued his work in Cange by commuting between the two for three years. He had to take long absences from medical school but still managed high grades. “The experience he was gaining treating the poor and sick in Haiti was more instructive than any classroom lecture.”

He founded a community-based health project in Cange. He and his team started a two-room clinic in 1985. Despite an army coup and political upheavals in Haiti, Paul and his team continued their work. Paul wrote an article in the Harvard Medical School journal about his work and the conditions in Cange. It caught the eye of the owner of a large construction company in Boston who decided to visit Cange. Convinced of Paul’s effort, he started supporting it.

In 1986, the healthcare workers in Cange identified the first case of AIDS. This is considered to be one of the original flashpoints of the AIDS epidemic. This is when, with the help of some of his comrades, Paul decided to set up a charitable foundation called Partners in Health. Among the people who joined him in setting up PIH was a Harvard Medical School student Jim Yong Kim, who later became president of the World Bank (2012-2019). Together they built up the project from a two-room clinic to a complete hospital with a nursing school, operating rooms, telemedicine and a blood bank. It employed healthcare workers from the local community and provided them with training. They worked on the determinants of health at the same time by dispensing food and clean drinking water, provided housing assistance, education and social services. They built schools, houses, communal sanitation and water facilities and vaccinated all the children.

All this resulted in a dramatic reduction in malnutrition and infant mortality. Locally developed therapeutic strategies for preventing and controlling infectious diseases, such as tuberculosis, reduced costs to 100th of the amount that treating the same disease would have cost in a hospital in the US. Women literacy and AIDS prevention were great successes. This model of care and its impact was inspiring and started being replicated in other places.

One of the reasons for the dissemination of the work of PIH in Haiti was the prolific writing by Paul Farmer about their work. He wrote a series of books, including AIDS And Accusation, The Uses of Haiti, Infections And Inequalities, Pathologies Of Power and To Repair The World. Tracey Kidder wrote a book about the work of Paul Farmer and PIH in 2003, Mountains Beyond Mountains — The Quest Of Dr Paul Farmer, A Man Who Would Cure The World, which won the Pulitzer Prize. A good documentary was also made on PIH titled Bending The Arc. Paul became an icon for improving healthcare for the poor. All big donors started supporting PIH’s work. WHO used the Cange experience in infectious disease control in a number of countries and many awards were bestowed on Paul which he donated towards furthering the PIH work. President Clinton selected Paul Farmer as a deputy special UN envoy to Haiti.

As a celebrated icon and role model, Paul used all his charismatic influence to set up the first of its kind University of Global Health Equity in Rwanda with the support of the Rwandan government and a number of donors. The university has been up and running for the last few years now. This is where Paul breathed his last on Feb 21, 2022 while sleeping. He was 62.

Today, PIH has projects in a number of African and other developing countries which are aimed at transforming healthcare for the poor.

The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University and WHO adviser on UHC.

zedefar@gmail.com

Published in Dawn, July 15th, 2022