ICU and You · Notable Doctors · Number 2
Paul Farmer, 1959–2022
This one was not my idea. The first of these columns ended by asking whose name should be in it. Maheshani wrote back with Paul Farmer, and with her reason, which I am going to borrow because it is better than anything I had:
“His work showed how compassionate clinical care, public health and research can come together to improve healthcare for people in disadvantaged communities.”
That is the argument. What follows is an attempt to show it happening, in one documented sequence, rather than to assert it.
In 1993 the Director-General of the World Health Organization put the cost of treating one patient with multidrug-resistant tuberculosis at up to $250,000, said the conditions for it could be met “only in the industrialized countries and in sophisticated hospital settings”, and concluded that for those who developed it in the developing world the disease was “a virtual death sentence”.
By 1997 WHO's own guidelines were telling national programmes to triage, placing patients who had already failed retreatment at the lowest priority. The phrase doing the work in all of this was not cost-effective. It was not a claim that the treatment did not work. It was a claim about who could be afforded.
Paul Farmer was born in North Adams, Massachusetts, in 1959, the second of six children. When he was about seven his father bought a school bus, converted it and moved the family into it; later they lived on a houseboat in Florida. In his own words: “from the time I was ten, until many, many years later, I never lived in a house.” One summer, money short, the family picked citrus alongside Haitian migrant workers. That was where he first heard Kreyòl.
He went to Duke on a full scholarship, read anthropology, and graduated in 1982. He then took an MD at Harvard Medical School and a PhD in anthropology, finishing both in 1990. He trained in internal medicine and infectious diseases at the Brigham and Women's Hospital in Boston, and he was still seeing patients thirty years later.
In 1983, not yet a medical student, he went to Haiti. He and Ophelia Dahl were invited to the village of Cange by Père Fritz Lafontant and his wife Yolande, who ran an Episcopal mission there. The story is usually told as though Farmer arrived and founded something. He did not; he was asked.
Cange sits above Lake Péligre, and the lake is the point. The Péligre dam was designed by the US Army Corps of Engineers, financed by the Export-Import Bank of the United States, and completed in 1956. It flooded the valley. Thousands of families lost their land, most of them without compensation, and many left at the moment the water began to rise. The people Farmer spent his life treating were the descendants of people a development project had dispossessed. That observation — that poverty arrives through decisions somebody made — became the argument he is known for.
What grew out of the mission at Cange is now Zanmi Lasante, fifteen clinics and hospitals with over 6,300 staff, serving more than three million people. It is the largest non-governmental health provider in Haiti.
This is the part that answers Maheshani's claim, and it is worth taking slowly, because every link in it is documented.
It starts in a clinic. Farmer's own tuberculosis patients in Haiti did better when they were given food alongside the drugs — a cure rate of 100% against 56% for the medication on its own. That is a clinical observation, made by a doctor who was there, about why his patients were not getting better.
It becomes a research question. In 1996 Jim Yong Kim, Farmer's co-founder, identified an outbreak of multidrug-resistant tuberculosis in Carabayllo, a poor district of northern Lima. The orthodoxy said these patients could not be treated. Partners In Health treated them anyway, with second-line drugs, delivered at home by community health workers who also dealt with the food, the transport and the rent. In 1998 Farmer and Kim published the argument for it in the BMJ, and gave it a name: DOTS-Plus.
It becomes evidence. In 2003 Carole Mitnick, Jaime Bayona and Peruvian colleagues published the outcomes in the New England Journal of Medicine. Eighty-three per cent of patients who were properly treated and supported did well — against roughly 48% under the protocols WHO was then recommending.
It becomes policy. WHO convened a working group on DOTS-Plus, issued guidelines in 2000, and established the Green Light Committee that year: programmes that met the standard got access to quality-assured second-line drugs at a negotiated price. In July 2001 WHO announced that the cost of those drugs had fallen by as much as 94 per cent. By 2015 there were more than a hundred such programmes.
And then it is checked. In 2006, in PLoS Medicine, an independent group ran the sum the original objection had rested on and found that treating multidrug-resistant tuberculosis was, in fact, cost-effective. The orthodoxy was not beaten by rhetoric. It was beaten on its own terms, thirteen years later, by people who had already treated the patients.
He had a word for the method, and he took it from liberation theology. To accompany someone, he told a Harvard graduating class in 2011, “is to go somewhere with him or her, to break bread together, to be present on a journey with a beginning and an end”. It means staying with a task “until it's deemed completed by the person or people being accompanied, rather than by the accompagnateur” — which, he noted, is not the same as a paid consultancy or a one-off project.
That is not a sentiment. It is a job title. Partners In Health employs around fourteen to eighteen thousand people across a dozen countries, and roughly 98% of them are from the communities they work in; its community health workers are called accompagnateurs.
Five things the popular version gets wrong. The line everyone quotes — “the idea that some lives matter less is the root of all that is wrong with the world” — comes from Tracy Kidder's book about him, not from anything Farmer wrote; his own version, from a 2015 address, is “our species gets into trouble any and every time we consider someone to be less than human”. He co-founded Partners In Health rather than founding it, and PIH's own pages disagree about who was in the room in 1987. He was invited to Cange by the Lafontants rather than arriving at an empty place. Kim identified the Peru outbreak and Mitnick led the paper that proved the case. And the 94% fall in drug prices is credited by WHO's own announcement to WHO, Médecins Sans Frontières and Harvard Medical School — not, as it is usually told, to Partners In Health.
Farmer was close to power — to Bill Clinton, to the United Nations — and the serious criticism of him is that the closeness bought silence. The journalist Ansel Herz set it out in 2013: that Farmer gave no clear answer when asked about United States opposition to raising Haiti's minimum wage; that he stayed publicly muted on the United Nations' responsibility for introducing cholera to Haiti in 2010, while sitting on the board of an organisation suing the UN over it; and that his responses to the exclusion of a major party from the 2011 elections were thin.
Herz writes from an avowedly adversarial position, and Farmer answered: that his power was limited, that he had said what needed saying after the earthquake, and that he preferred practical intervention to litigation. Readers can weigh that. It is in the piece either way, because a profile that leaves it out is an advertisement.
Partners In Health went into Rwanda in 2005. In 2015 Farmer co-founded the University of Global Health Equity at Butaro, in the north of the country, where every student is funded, the medical class that opened in 2019 was majority female, and the students come from thirty African nations. He was its chancellor.
He died at Butaro on 21 February 2022, in his sleep, of an acute cardiac event. He was sixty-two, and he had been teaching. He was seeing patients until the end.
Maheshani's sentence was that compassionate clinical care, public health and research can come together. The usual version of that idea is a diagram in a strategy document. What Farmer left is narrower and much harder to argue with: a man noticed that his patients got better when he fed them, said so in print, kept treating people everybody else had written off, and the sum that had been used to justify writing them off was eventually run properly and came out the other way. Nothing in that sequence required him to be a saint. It required him to keep seeing the patients in front of him and to refuse to accept that the arithmetic had already settled the matter.
Whose name should be in this column?
Nominate a doctor — famous or entirely unknown, alive or long dead, yours or somebody else's — and tell me in a line or two what their working life added up to. I will research it and write it.
Or write it yourself and I will publish it, with your name on it or without, as you prefer. Anonymous is a perfectly good byline and some of the best ones will need it.
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