Paul Farmer's lasting legacy: The quest for equity in global health

Five days after his unexpected passing at 62 in Butare, Rwanda, Dr. Paul Farmer’s transformative role in global health and medical anthropology is coming into focus amid an outpouring of testimonials to how he confronted and reconceptualized notions of who deserves care.

In his career, Farmer took on outbreaks of HIV, Ebola, and other infectious diseases. He approached them both as a physician committed to treating sick patients, but also as a medical anthropologist determined to understand the political and social causes that created the “medical deserts” in which the emergencies occurred.

“What was transformative was this understanding he promoted of how social forces become embodied as pathology,” said Dr. Eugene Richardson, Farmer’s colleague at Harvard Medical School. “The focus has to be not just on giving pills, but on structural interventions.”

Farmer’s lifelong engagement with global health began after he finished his undergraduate degree at Duke University in 1982 and moved to Haiti’s central highlands to work with dispossessed farmers. With Ophelia Dahl, another volunteer, he built a health clinic in Cange, a remote village. It would prove the origin of Partners in Health, the organization he would co-found with Dahl and others in 1987.

As chief strategist of the organization, he oversaw its expansion into 11 other countries, working with national governments to provide care and strengthen public health systems.

Farmer was completing his own education even as he was building PIH, graduating from Harvard University in 1990 with a medical degree and a Ph.D. in Anthropology. Harvard Medical School would remain his professional home. He helped usher in the Program in Infectious Disease and Social Change and ultimately became chair of the Department of Global Health and Social Medicine. But his vision always extended beyond Boston.

“He moved easily between settings of poverty and places of power and he was able to make those connections,” said Dr. Arachu Castro, a public health specialist at Tulane University, who worked closely with Farmer on community-based approaches to HIV treatment. “He was trying to get as much support as he could for his plans, which were extremely innovative in a world that had basically decided that the poor were not worth investing in.”

At the heart of these efforts, colleagues said, was a dedication to reconceptualizing global health.

“He put the interactions at the center of his anthropological focus, the clinical interactions, patient behaviors, and social determinants, and then put that in a broader critical perspective,” said Dr. Rachel Chapman, a professor of anthropology at the University of Washington. But to understand those interactions, “he was saying we actually need to look at the political power dynamics.”

That led him to demands as fundamental as renaming the field.

“Do we want global health … to be radically different from colonial health or tropical medicine,” he asked in an interview last year. “If so, then let’s stop referring to it as ‘global public health’ or ‘global health security’ and start calling it ‘global health equity.’”

In that reframing, he saw the beginning of a fundamental reorientation of a system that was “overtly colonialist in nature and focused on control over care. The idea behind ‘global health equity’ is to break that bond. To do that, we must address health disparities wherever they occur.”

Farmer did not stop at addressing the disparities, though. He demanded understanding and accountability for their causes.

He pointed to the willingness of leaders and institutions in high-income countries to accept the scarcity that existed in the global south, but also to persist with narratives that rewrote the historical roles colonizing countries had played in creating and perpetuating those scarcities.

In response to the violent extraction practiced under colonialism, he called for reparations.

“It was not just going to open more clinics in resource-stolen areas,” said Richardson, who sat on The Lancet Commission on Reparations and Redistributive Justice with Farmer. “You have to do the strengthening part, but also repairing legacies of colonialism, imperialism, slavery. That is part of social medicine.”

Farmer sounded the drum for those demands in his classes at Harvard, his multiple books, and frequent interviews. More significantly, colleagues said, he integrated them into his own practice, especially in PIH’s work.

“PIH doesn’t develop a program and come to a country and say this is what works,” said Dr. Mohamed Bailor Barrie, who heads the organization’s Sierra Leone office. “We never do things in isolation. Anything we want to implement, we involve the ministry in developing strategies.”

Farmer’s philosophy extended beyond supporting Indigenous initiatives and building local capacity, though. It was premised on “being a house of yes, not a house of no,” Barrie said. “If somebody asks you for something we’re not planning to do, saying no to something is stopping the conversation, stopping the opportunity that exists for solving that problem.”

It was an approach that spurred a constant evolution. During a discussion at Harvard, he explained that PIH’s original mission included more than serving the poor and meeting their needs, which dominated the organization’s early efforts, but also linking people in resource-poor settings to the kinds of training opportunities offered to students at Harvard and then building their capacity.

Those latter elements were increasingly the focus of his time and attention, including the University Hospital of Mirebalais created by PIH after Haiti’s 2010 earthquake and the University of Global Health Equity in Butare, Rwanda, where he was working when he died.

“It has been a major challenge to keep these institutions funded, but I believe they’re important markers of an attempt to decolonize global health and expand access to first-rate training opportunities,” he said in a 2021 interview.

A celebrity in a field that generally goes under-recognized, Farmer received a MacArthur Foundation “genius award” in 1993 and the $1 million Berggruen Prize for Philosophy and Culture in 2020.

That recognition also exposed him to questions about whether he was crowding out voices from historically marginalized communities. Chapman, who helped organize a 2018 discussion at the University of Washington, said students “understood he had all this power and wanted him to deconstruct it.”

Colleagues said he remained conscious of his position as a white man educated in elite U.S. institutions, as he sought to reimagine and decolonize global health, welcoming critiques, and fighting to elevate others.

Barrie pointed to his practice of boosting researchers from Africa and making sure they received the authorship recognition their contributions merited.

“He should be remembered for improving, extending the life expectancy of thousands of people around the world,” Castro said. “And also for leaving a legacy among those who worked with him or trained with him. That will have a huge ripple effect.”