“What happens to poor people is never divorced from the actions of the powerful,” Paul Farmer wrote in his 2005 book Pathologies of Power. A doctor, medical anthropologist and activist, Farmer devoted his life to advocating for health equity. As a co-founder of Partners In Health (PIH), a non-profit organization that provides free medical care in low-income countries including Haiti, Peru and Rwanda, he used the group’s results to change global guidelines on how to treat tuberculosis and HIV. During the COVID-19 pandemic, Farmer and his colleagues denounced monopolies on vaccines that help to account for why fewer than 10% of people have been fully vaccinated in low-income countries (P. Erfani et al. BMJ 374, n1837; 2021). Farmer treated patients up until his death in Rwanda, aged 62.
In 1990, he earned a PhD in anthropology alongside a medical degree from Harvard Medical School in Boston, Massachusetts, where he later taught global health and social medicine. His views 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 his thinking on the systemic oppression of poor people.
Farmer’s 12 books and more than 200 manuscripts reveal the principles that guided his actions. The money needed to save lives exists if lives are valued equally, Farmer argued. He criticized the public-health field for cost-effectiveness analyses used by governments and donors to calculate when medical technologies that they take for granted are worthwhile for those who cannot pay for them themselves. In an editorial in the World Health Organization Bulletin in 2003, he criticized those in the public-health community who pushed for HIV prevention rather than care in poor countries because it was cheaper (P. Farmer Bull. World Health Organ. 81, 699; 2003). At the time, HIV drugs were astronomically expensive — but did not need to be, 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 sometimes bent the rules. In the early days of PIH in the 1990s, he and co-founder Jim Yong Kim smuggled some US$92,000-worth of second-line tuberculosis drugs out of Brigham and Women’s Hospital in Boston, Massachusetts, where they both worked, 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 threw their support behind an ambitious World Health Organization initiative to treat three million people with HIV/AIDS by 2005. They understood that donors prefer to fund programmes that focus narrowly on a single disease, rather than on health care broadly.
In private, however, they wanted to restructure systems, says Farmer’s close colleague, Adia Benton, an anthropologist at Northwestern University in Evanston, Illinois. “They knew that to get this many people on HIV care, you’d have to change patent law, you’d have to change manufacturing, you’d have to build obstetrician–gynaecology clinics. He’d argue that you can’t take care of maternal-to-child transmission without good prenatal care,” she explains. “They were hustlers.”
PIH stands apart from most other aid organizations in that it attempts not only to build clinics but also to ensure they remain sustainable by operating within government-run services and enlisting local staff at every level. “I am a living testament to that,” says Bailor Barrie, the executive director of PIH Sierra Leone, a branch established during the Ebola outbreak in 2014. Farmer and Barrie met when the latter was a global-health student in Farmer’s class at Harvard Medical School. “He is my teacher, my mentor, my colleague, my friend. I call him Pa because he is like a father,” Barrie says. “I am devastated.”
Farmer encouraged scientists studying diseases to account for forces such as racism, sexism and poverty that hinder people’s abilities to take advantage of the fruits of science. Although rooting out the sources of oppression is a tall order, Farmer described how medical programmes could work better if they strove for equity (J. S. Mukherjee et al. Lancet Glob. Health 7, E410–E411; 2019). In that paper, he wrote about how 100% of people who received small monthly stipends and food alongside free tuberculosis treatment from his team in Peru were cured of the disease, compared with only 56% of those given the drugs alone.
Benton suggests that Farmer’s political orientation stemmed from his experience of growing up in relative poverty: one of six children, he lived in a bus, a boat and a tent. His medical care for a broken leg as a graduate student in 1988 cost about twice his mother’s annual salary as a cashier, he once wrote in the London Review of Books. He reflected that most of his bill was covered by Harvard’s medical insurance, whereas such health costs impoverish some 30 million households each year around the world — if people get care at all. “Three of the Haitian founders of PIH, all in their twenties, had recently died stupid deaths,” he wrote, of the preventable and easily treated diseases of sepsis, malaria and typhoid fever.
Farmer spent his career trying to convince people that health care is a human right. For this, he became a celebrity in global-health spheres. He leaves a legacy of researchers committed to carrying his mission forward. “He wasn’t just a guy with a vision,” Benton says. “He was brilliant.”