Thammasat University students interested in the Allied Health Sciences, global health, social medicine, development studies, political science, sociology, and related subjects may find it useful to remember the achievements of Dr. Paul Farmer, who taught at Harvard Medical School in Cambridge, Massachusetts, the United States of America.
The Thammasat University Library collection includes several books coauthored by Dr. Farmer, who died recently in Rwanda, where he had been teaching at the University of Global Health Equity, a medical school that he cofounded.
Dr. Farmer worked to communicate the message that all human lives are equally important, and lack of money should not mean access to inferior medical care.
In an in-depth interview from 2020, Dr. Farmer described the struggles of caring for impoverished people under difficult conditions:
Some people have a rich life of faith, others have distracting hobbies, others are doing such varied work that their sadness is leavened by a lot of satisfaction—like when the team in Sierra Leone gets the Maternal Center of Excellence up and running, you’ll be floating on that happiness, right? Years and tears later, I’m still happy about University Hospital in Haiti, still thrilled about Butaro Hospital in Rwanda, and the University of Global Health Equity next door.
All three of those things are meaningful to me: spiritual engagement, distracting hobbies—mine happens to be gardening—and that network of friends who stick together in this work long enough to see the progress and joy that invariably attends this work. It’s really more about joy and progress once you stick with it. If I go back to my hypothesis that a lot of people in global health could stand a little bit more sadness, it’s not that I wish sadness on them. But I wish the kind of passion that we have on all of them. And I think that, for most, passion comes from proximity…
Even when I was still a medical student, I found hard-core disease control unnerving—all of your attentions are focused on stopping spread of a pathogen without adequate attention and resources for treating people suffering from said pathogen.
Where in the world was the priority most reliably placed exclusively on disease control with little interest in the care afforded the natives? This paradigm came into being during colonial rule. Year in, year out, epidemic this and epidemic that, I could find some undercurrent that said: ‘Good, high-quality medical care is for us—not for you, Black people and brown people. We got disease control for you.’
With Ebola, people would misinterpret the international community’s response. They said, “Billions of dollars were put into Ebola care.” That’s bullshit. There weren’t billions of dollars put into Ebola care—if there were, we would have had similar case fatality rates to what we saw in Europe or in the United States.
We found plenty of people in the public health community saying, “It matters a great deal to me that people get better care.” But early on in the epidemic, the mediocrity of the quality of care was not raised militantly and persistently. And by the time these massive investments—which were a lot smaller than we were led to believe—were made, it was too late. The majority of purpose-built Ebola treatment units never saw any patients…
When things like COVID-19 come along, people are suddenly more aware of the fragility of our grasp on flourishing. So the solutions that are proposed in this book, which include such concepts as health system strengthening, building safety nets, and building out insurance for unemployment, catastrophic illness, and funerals—all of that can be viewed through the lens of COVID, too.
Our work, which is around health system strengthening and all of what I just mentioned, never enjoys adequate financial support. A book like this isn’t going to generate the resources. But if it generates the understanding that leads to corrective investments, that would be a great thing to have contributed to.
In 2018, he responded to another interviewer about how he avoided burnout:
GAZETTE: Do you still love what you do?
FARMER: Oh yeah, more than ever. I love the work I get to do and the chance to see patients in radically different settings. Some people would find the travel part of it unsettling. I just came back from Delhi, Mumbai, and West Africa via Texas. It was great to talk to college students in Texas, where I was predictably asked, “How do you avoid burnout?”
GAZETTE: It’s a good question.
FARMER: The students always ask it. I said, “You know, I compare myself to my classmates from med school, Class of ’88. I’m at less risk than any of them for burning out.”
You’ve got to do what you really like. I’d like to see all of my own students here be happy and productive, and know from teaching here and elsewhere that this requires a great diversity of opportunities and experience.
GAZETTE: You’ve spent so much time at Harvard and in places that are very much not like it, where poverty is a big problem and sickness is a bigger problem. Do you get whiplash going from one situation to another?
FARMER: When I went to college, it was a cultural shock to go from rural Florida to Duke and then to Boston. That summer after freshman year, I starting coming here to the Longwood Medical Area, where I worked in a clinical lab at the Deaconess. It wasn’t of the order of culture shock going from Duke to Haiti after college, but you still aren’t entirely sure what world you belong in.
Haiti was a much more fundamental shock and it was a good one. But that wasn’t really about geography or language or culture; I loved those shocks. It was about extreme poverty…
GAZETTE: How important to your career is the blend of medicine and anthropology?
FARMER: It was and is very important. Any youthful dismissal I might have made about being an anthropologist is ridiculous. I think only young, callow folks do that, downplay their good fortune. I know my clinical work and the work of Partners In Health and my own research have all been informed by it. And then each year, as time goes by, I think, Wow, any insights I might have are related to my training in anthropology.
GAZETTE: The social determinants of health — ?
FARMER: But also the social construction of our interpretations. Understanding social determinants — anybody can do that and everyone should. Political economists had that work down in the 19th century, and what’s-his-name — Hippocrates — wrote all about it. The social construction of epidemics and the lived experience of sickness are very different.
Social construction of the way we interpret these determinants means knowing that our views on illness, well-being, sickness, death, suffering, pain, equity, fairness, and justice are all socially constructed and therefore amenable to change. None of it is God-given. Understanding that — that’s really anthropology.
GAZETTE: It seems like one hallmark of your career has been questioning the conventional wisdom, particularly around treating poor people. Is that related?
FARMER: I think they’re very related. It could be that I’m overwhelmed at the beauty of my own logic, but to say, “Wait, these are not God-given, they’re socially constructed,” means that received wisdom often constitutes a big problem explaining the unequal distribution of disease, suffering, pain, and death. Explaining any of it as the natural order of things blocks meaningful change.
