The radical plan to honor Dr. Paul Farmer — by remaking global health

The first time Jan Schakowsky, a longtime U.S. representative from Illinois, met the late Dr. Paul Farmer was in 2003 during a visit to Cange, the Haitian village where Partners In Health’s sister hospital Zanmi Lasante, provides medical care to anyone who needs it.

Several things stood out to Schakowsky: The hospital that was both “barebones” and “state of the art,” the way that community health workers were entrusted to deliver essential care, and the beauty of the hospital’s gardens.

“It was not just efficiency; it was about beauty as well. And all these places that he created were so beautiful for the poorest people in the world,” Schakowsky told Devex in an interview.

But it was one experience, in particular, that left a permanent mark. Schakowsky remembers a boy in one of the hospital beds, about 12 or 13 years old, who Farmer told her was not expected to live much longer.

“[Farmer] sat down on that bed, and he held this boy's hand and talked to him and stroked him in such a personal and profound way,” Schakowsky said. The boy died shortly afterward.

“I believe that he died feeling loved, cared for, valued,” Schakowsky said.

Schakowsky remained a close ally of Farmer’s for the next two decades. When Farmer died unexpectedly in February, Schakowsky began to think about how to honor his work and spread his message that every person in the world has a right to quality health care. She reached out to Partners In Health to come up with a plan.

The result is the Dr. Paul Farmer Memorial Resolution, which Schakowsky introduced in Congress last month alongside Rep. Raul Ruiz, a Democrat from California, and Rep. Barbara Lee, a Democrat from California.

The resolution sets out a three-part strategy for the future of U.S. global health efforts. If the U.S. government were to pursue the agenda outlined in the resolution, it would completely transform America’s role as a global health leader, massively increase the amount of funding available for these programs, and require a fundamental rethink of fairness in the global economy.

“Welcome to the world of Paul Farmer,” Joia Mukherjee, Partners In Health’s chief medical officer, told Devex.

 A $125 billion U.S. global health budget

The resolution’s supporters see it as phase one of a broader effort to engage people with a vision of global health drawn from Farmer’s scholarship and moral leadership. They do not expect the resolution to pass. And even if it did, because it’s a resolution and not a bill, it would only convey the collective opinion of the Congress, rather than establish any binding new laws.

The resolution’s first proposal is to increase U.S. global health aid to $125 billion a year. That is roughly 10 times what the U.S. government currently spends.

While that figure appears impossible in the context of current debates over the appropriate size of the U.S. foreign aid budget, the broader message is that it shouldn’t be. Part of the problem is that global health advocates have accepted as normal a status quo that is wholly inadequate to confront the challenges they face, the resolution’s supporters argue.

That’s a message that comes straight from Farmer who critiqued the “socialization for scarcity” within global health that leads people working in the field to take as a given that they should be operating with limited resources and pitting one priority against another.

Farmer raised the issue in an interview with Devex back in December 2014, during the Ebola outbreak in West Africa.

“I’m just trying to stand back and say, why is our starting point always, we have scarce resources? Who said? What would we not give now to have intervened in between December and May? … If we’d done the things that we’ve advocated now — improved infection control, bring in staff, space, stuff, systems — you wouldn’t have a runaway epidemic,” he said.

His words could apply just as well to COVID-19. The staggering human and economic toll of the pandemic has only made his argument stronger, his acolytes say.

They also point out that a substantial increase in U.S. aid spending would be required for the U.S. government to meet an international target to direct 0.7% of gross national income to aid, which donor countries have endorsed in principle but mostly ignored in practice. 

While the U.S. government is the largest bilateral aid donor in total dollars, U.S. foreign aid spending ranks near the bottom among peer donors as a fraction of GNI, at roughly 0.2%.

“If the U.S. were to reach that, it would really transform our ability to do global health in the world,” Mukherjee said, adding that, “We have to put it in the light of the trillions of dollars that have been spent on dealing with an unchecked pandemic.”

“This is not like pulling a number from the sky. This is about commitments we have made, ideas of where it would come from, where it would go, and how it would be spent,” she said.

A fairer global economy

The resolution also identifies structural factors in the architecture of global health and the global economy that undermine universal access to health care.

It calls for reforming U.S. global health aid to “focus on building national health systems and direct funding to local partners, not the development industry.”

“The way the aid complex has worked is by supporting mostly American NGOs that do not necessarily follow the national plans of governments and often have their own agenda, fragmenting aid across the country,” Mukherjee said.

Perhaps most ambitiously, the resolution calls for large-scale reforms to “make the global economy more fair, just, and democratic.”

These include giving low-income countries greater voice at multilateral institutions, “global debt cancellation for all developing countries that need it,” tackling licit and illicit financial flows that have seen more capital flow from low-income countries to high-income ones than vice versa, and support for global labor rights.

“The economic system is keeping these countries very, very poor and very cash strapped, and … until we can do something about that, we can't just say, ‘oh, this needs to be sustainable,’ because we've created an environment whereby people have no operating budget,” Mukherjee said.

Schakowsky and her resolution co-sponsors plan to use it as a platform to engage people in conversations about the importance of global health, build a coalition for thinking bigger about the U.S. government’s role, and subsequently introduce concrete pieces of legislation that could advance aspects of the strategy outlined in the resolution.

“[U.S. President] Joe Biden has said to the world, ‘the United States is back.’ So let's be back in a way that can help us here at home and then internationally as well," Schakowsky said.

“At least through a piece of legislation like this, we can have a conversation about these bigger ideas and socialize those ideas,” she said.

Update, Oct. 6, 2022: This article has been updated to clarify the resolution filed by Rep. Schakowsky and the year she went to Haiti. It also updates the state where Rep. Raul Ruiz represents a district.