'We're not doing enough': Doctor urges equal health care for the most vulnerable

Dr. Paul Farmer was a towering figure in global public health. As a co-founder of Partners in Health, he sought to radically change ideas about healthcare and who deserves it. Dr. Farmer died suddenly in his sleep earlier this week. He spoke to IDEAS in May of 2020.

People looking out for each other is the only way forward, says Dr. Paul Farmer

'It's just crushing to me after all these decades to say that a virus is going to come along and be the great leveler,' says Dr. Paul Farmer about COVID-19. The physician, anthropologist and co-founder of Partners in Health has spent more than three decades working in some of the world’s most vulnerable communities. (Rebecca E. Rollins/Partners In Health)

*Originally published on May 1, 2020.

UPDATE: Dr. Paul Farmer was a towering figure in global public health. As a co-founder of Partners in Health, he sought to radically change ideas about healthcare and who deserves it. Sadly, Dr. Farmer died suddenly in his sleep on Feb 21, 2022, at the age of 62. In May of 2020, he shared his thoughts with IDEAS about equity and humanity in healthcare. 

Paul Farmer was 22 years old when he arrived in Haiti. The physician and anthropologist had just started medical school at Harvard University and was keen to see where and how he could help some of the most vulnerable people get access to health care. 

He was by his own account "an idiot" albeit one who was earnest, eager, and curious — and he admits he was not prepared for the level of social and economic insecurity he saw.

I wouldn't want to relive those early years. I don't have any romantic recollection of them.- Dr. Paul Farmer

The level of need and inadequacy of the response offered Farmer and his colleagues a sobering lesson.

"That kind of insecurity that I saw during those days, during that first year — during those first several years, all the work that we did trying to make a difference and knowing that we were not making a difference, that's very hard medicine," he told IDEAS.

"It took years of seeing mediocre work. It took years just to recognize it. And there's no excuse for that, because, you know, to go between Harvard and Haiti is to be faced with a regular and dramatic contrast."

And later in other locations — like rural and urban Peru, in slums, and in rural Rwanda which had no hospitals — it was starkly clear to Farmer and the other doctors: "We're not doing enough."

"I wouldn't want to relive those early years. I don't have any romantic recollection of them," Farmer said.

'Socialized for scarcity'

Farmer and his colleagues went on to establish Partners In Health. The goal was to bring a high standard of public health care to the most vulnerable communities around the world. The work began with a radically different understanding, one that pushed back against the prevailing wisdom in public health sectors that poor people were entitled to little more than the bare minimum.

"Back in those days, in the '80s, it was an era of low expectation, the rise of neoliberalism, uncontested, and even unrecognized. You were just soaking in it all day long," Farmer said.

Former U.S. President and U.N. special envoy for Haiti, Bill Clinton, toured the General Hospital in Port-au-Prince with Farmer of Partners in Health, in 2010. (Lynne Sladky/The Associated Press)

"When I was a first year medical student, I remember having a debate that was couched as an ethics debate in which we were taking sides about whether we need more neonatal intensive care units (NICUs) in the United States or better prenatal care for women of colour. And, you know, it sounds good for a while. It sounds like a weighty choice. And then you stop and think, wait, why would we choose between taking care of premature infants and providing prenatal care? Why would we do that?"

Farmer says the debate "started to fall away" from him when he witnessed a young woman in Haiti die in childbirth. She died of a hemorrhage in her third trimester.

"And you say you never want to see that again. But you do. And you realize that, no, prenatal care is not going to solve that problem. That requires a health system that can respond with blood that's safe and banked with operating rooms on a 24/7 call schedule. Those are things that require a real system."

The neoliberal view of public health care which manifests as providing the least resources for the weakest among us is layered on top of lingering colonial views of what "the natives" deserve, said Farmer.

PIH's mission is to upend the ideas that underpin the "least for the weakest" model but it's not an easy fight. Policymakers, academics, health-care providers, and schools of public health are, as Farmer puts it, "socialized for scarcity."

"To be socialized for scarcity is to say, well, you know, it's not cost effective, it's not sustainable, we don't have the resources, it's not a priority. There's a long list of excuses. They'll all be familiar to you," he explained.

A member in a Partners In Health-supported oral cholera vaccination campaign fills out a patient's form in Penier Siwal. PIH delivers comprehensive health care in some of the poorest, most remote regions of Haiti, with the help of the national Ministry of Health. (Cecille Joan Avila/Partners In Health)

It is where those voices are coming from that is important, added Farmer, because he says they're not coming from the people who themselves face those risks or their family members or even their caregivers. 

"My surgical colleagues who are saving their colleague from a hemothorax in the middle of the night in rural Haiti are not saying, 'It's 2 o'clock in the morning, the blood bank's closed,' or, 'Sorry, we just have a skeleton crew because of COVID-19.'"

It's often from schools of public health, from policy-setting bureaucracies who are setting policies for other people, not themselves. "They are socialized for scarcity on behalf of other people."

Pragmatic solidarity

Farmer points out that the vast disparity in health care is not only between richer countries and poorer ones.

He says it's important to remember that the chasm exists within richer countries as well, that the kind of vulnerabilities faced by displaced people, or those living in informal communities also affect marginalized and racialized people in countries like the United States and Canada.

The only way to begin closing the gap is to think about health care as an equity question. Health-care services and delivery need to be structured to prioritize the weakest and most vulnerable first since they are the ones least shielded from illness.

Lucia Filimoni walked four hours from her home in Malawi to deliver her sixth child at Dambe Health Centre. Filimoni and her baby, Harry, are seen here the following day being cared for by Nurse Charles Malindi. Partnership in Health, known locally as Abwenzi Pa Za Umoyo, collaborates with Malawi’s Ministry of Health to provide comprehensive care for about 160,000 people in Neno. (Jeanel Drake/Partners In Health)

Farmer points out that in the current COVID-19 pandemic, African-Americans are dying at disproportionately high rates explained, in part, by lower rates of health insurance — but also because of higher proportions of health risks like poverty.

To begin addressing the problem, he says people need to come together with a sense of pragmatic solidarity. He has written elsewhere that pragmatic solidarity is more than just compassion. It is compassion linked to the practical work of reducing suffering.

He says seeing the pragmatic solidarity on display daily from his colleagues in places as diverse and disparate as Haiti to Rwanda and Navajo Nation to Peru, he is filled with hope.

People working together and looking out for each other is the only way forward, Farmer said.

"I think it opens up a huge realm of possibility to have more of a beloved community that crosses some of these boundaries of race and class and poverty and insurance status. It's worth a lot to give that a try." 

About our guest in this episode:

Paul Farmer was a medical anthropologist, physician and a co-founder of Partners in Health, a global health-care non-governmental organization. He was also the Kolokotrones University Professor of Global Health and Social Medicine at Harvard University and he sat on board of Partners in Health, Canada. Dr. Farmer died on February 21, 2022.

* This episode was produced by Naheed Mustafa.

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