All achievers

Paul Farmer, M.D.

Global Health Crusader

Women who live in poverty love their children as much as anybody else does.

Paul Farmer was born in West Adams, in Western Massachusetts, the second of six children. When he was seven years old, his father, a salesman and high school math teacher, moved the family to Birmingham, Alabama, and five years later, to Brooksville, Florida, a small town north of Tampa, inland from the Gulf of Mexico. Here, the elder Farmer found jobs teaching, and working with developmentally disabled adults.

Farmer has described his father as “a free spirit.” When they moved to Florida, he housed his family in an old school bus he had converted into a mobile home, replacing the seats with bunk beds. He wired the bus with electricity, but it lacked running water. In the bus, the family of eight migrated from one trailer park to another. When the father decided to try his hand at commercial fishing, he moved his family to a houseboat in the Gulf. Tiring of fishing, the elder Farmer moored the boat in an undeveloped bayou called Jenkins Creek. The family bathed in the creek, and brought their drinking water back from Brooksville in jugs.

RWANDA. Rwinkwavu. 2005. Dr. Paul FARMER treats patients in his clinic in rural Rwanda. © Peter van Agtmael/Magnum Photos
2005: Dr. Paul Farmer treats patients in his clinic in rural Rwanda. (© Peter van Agtmael/Magnum Photos)

Despite his unconventional home life, he excelled in school. Both of his parents enjoyed reading serious literature to their children, and encouraged them to take an interest in the wider world. When money was short one summer, the family picked citrus fruit alongside Haitian migrant workers. This was Paul Farmer’s first encounter with Haitian people and their Creole language. It would not be his last.

Paul was elected president of his senior class at Hernando High in Brooksville, and won a full scholarship to Duke University in Durham, North Carolina. At Duke, he explored a variety of science courses before concentrating on medical anthropology. He spent half a year studying in Paris, where he attended some of the last lectures of the influential anthropologist Claude Lévi-Strauss. Farmer returned to North Carolina fluent in French; his skill at acquiring languages would serve him well in the years ahead.

At Duke, Farmer discovered the writings of Rudolf Virchow, the 19th century German physician and scientist who founded cell theory and pioneered the practice of public health medicine. Virchow’s approach, which encompassed biology, anthropology and politics, inspired the young Farmer. Events in the outside world had a profound influence on him as well. As Central America was ravaged by civil war, Americans were learning more about the doctrines of “liberation theology,” which informed the Catholic clergy’s resistance to the region’s military dictatorships.

Although Farmer had been confirmed in the Catholic Church as a teenager, his religious instruction had not dealt with the issues raised by liberation theology, and its emphasis on what the Church calls the “preferential option for the poor.” This doctrine regards a concern for the physical and spiritual welfare of the poor as an essential element of the Gospel. As some interpret the doctrine, the Christian’s first duty on earth is to aid the least fortunate of his fellows.

Dr. Paul Farmer examines a child in the pediatric ward of Rwinkwavu Hospital run by Partners In Health in Rwanda. (Eric Neudel for The Boston Globe)
Paul Farmer examines a child in the pediatric ward of Rwinkwavu Hospital run by Partners In Health in Rwanda.

Paul Farmer’s attention soon turned to the migrant labor camps not far from the Duke campus, where a Belgian nun, Julianna DeWolf, was working with the United Farm Workers to improve the living conditions of the laborers who harvested tobacco in North Carolina’s plantations. Through Sister Juliana, he came to know many farm workers, including a number of Haitian migrants. Their poverty made the circumstances of his own childhood seem luxurious, but the misery they had left behind in Haiti was even worse. Farmer was fascinated by their stories and began to learn everything he could about Haiti, studying the Creole language, interviewing migrant workers and reading scores of books about the island nation’s tragic history.

After graduating summa cum laude from Duke, Farmer completed a brief postgraduate fellowship at the University of Pittsburgh. He applied to Harvard Medical School, one of two institutions in the country to offer a joint-degree program in medicine and medical anthropology. In the meantime, he traveled to Haiti, where he planned to spend a year working in public health clinics, mastering the Creole language, and learning more about the country, the poorest in the Western Hemisphere.

The island of Hispaniola, discovered by Columbus, is today divided between Haiti in the west and the Dominican Republic in the east. The nation of Haiti was founded at the beginning of the 19th century, after a revolt by African slaves against their French colonial masters. Independence was followed by nearly two centuries of poverty, dictatorship and exploitation. Intervention by foreign powers — including a nearly 20-year occupation by the United States in the 20th century — had protected foreign business interests, but done nothing to alleviate the poverty of the majority of Haitians. When Paul Farmer first arrived in Haiti in 1983, the country was enduring the second generation of dictatorship by the Duvalier family. François “Papa Doc” Duvalier — followed by his son, known as “Baby Doc” — ruled by terror, suppressing all opposition through torture and murder.

Dr. Paul Farmer, founder of the medical charity Partners in Health, speaks on the opening night of the 2009 Summit.
Dr. Paul Farmer, founder of the medical charity Partners In Health, addresses the delegates and other Academy members at the introductory dinner of the 2009 International Achievement Summit in Cape Town, South Africa.

From the capital of Port au Prince, Farmer traveled into the countryside, where he met well-intentioned health practitioners starved for resources. The best-equipped facilities were inaccessible to the poor, and facilities for training local doctors, nurses and public health workers were completely inadequate. In the company of a Haitian Anglican priest, Fritz Lafontant, Farmer traveled to the island’s central plateau, where Father Lafontant had established a school and a rudimentary clinic in the town of Mirabelais. Beyond Mirabelais, Farmer visited the arid village of Cange. Here he found a community of squatters, displaced by the construction of the Péligre dam project, living in squalid huts with dirt floors and bark roofs, with no access to clean drinking water, education or medical care of any kind. Malaria, tuberculosis and typhoid were rampant.

In Cange, among the poorest and sickest of the poor, Paul Farmer found his calling. These were the people who needed his help the most. Father Lafontant had started a school in the village, and Farmer resolved to build a clinic there as well, one that would treat all comers, regardless of their ability to pay, and that would train and employ local public health workers.

Farmer was still in Haiti when he received word that he had been accepted at Harvard Medical School. He would simultaneously pursue a medical degree and a doctorate in medical anthropology. He returned to the United States to enroll, but having completed the formalities, he took his study materials back to Haiti. For the next three years, he would commute from Cange to Cambridge, returning to Harvard for exams and laboratory practice. The experience he was gaining treating the poor and sick in Haiti was more instructive than any classroom lecture. Despite his long absences, his grades were among the highest in his class.

Dr. Paul Farmer makes a presentation to a Haitian community group. Public health education is an essential component of his community-based approach to healthcare. (Gilles Peress/Partners in Health)
Dr. Paul Farmer makes a presentation to a Haitian community group. Public health education is an essential component of his community-based approach to healthcare. (Gilles Peress/Partners In Health)

In his first trip to Cambridge, Farmer secured funding from a small medical charity called Project Bread to build a bakery in Cange, assuring a supply of wholesome bread, a first step in addressing the chronic malnutrition afflicting the region. Along with Father Lafontant and Ophelia Dahl, a young Englishwoman who had also come to Haiti as a medical volunteer, Farmer founded a community-based health project, known as Zanmi Lasante.

In 1985, Paul Farmer and his colleagues opened Clinique Bon Saveur, a two-room clinic in Cange. That same year, Project Bread’s principal donor, Tom White, read an article that Farmer had written for a Harvard Medical School journal and asked to meet him. A Harvard graduate and World War II veteran, White ran a large construction company in Boston. White visited Farmer in Haiti and became convinced that Farmer’s project was worth all the support he could give it.

Facing a coup by his own army officers, Haiti’s dictator, François “Baby Doc” Duvalier fled the country in 1986. The military attempted to cling to power, but they soon faced a full-scale revolt from the suffering people of Haiti. At the same time, health care workers in Cange identified the community’s first cases of AIDS. The disease was already pandemic in Haiti’s urban slums. In the midst of this turmoil, Farmer set out to form a permanent charitable foundation to fund his work in Haiti. With Ophelia Dahl and his former Duke classmate, Todd McCormack, Farmer founded Partners In Health (PIH) in Boston, in 1987. Dahl would serve as president and executive director. Tom White contributed a million dollars in seed money. Another Harvard Medical School student, Jim Yong Kim, soon joined them. Like Farmer, Kim was an aspiring medical anthropologist with a particular interest in formulating effective treatment strategies for impoverished communities, and in negotiating with pharmaceutical companies for the best deals available.

In 1990, finishing his medical studies and earning a doctorate in anthropology, Dr. Farmer carried out a year’s residence at Brigham and Women’s Hospital in Boston. With his medical training and residence completed, Dr. Farmer was able to remain in Haiti for most of each year, returning to Boston for a few months at a time, sleeping in the basement of PIH headquarters. While in Boston, Dr. Farmer served as an attending specialist on the senior staff at Brigham, and launched a program in Boston’s inner city to contend with rising rates of HIV and tuberculosis.

Dr. Paul Farmer examines AIDS patient Thelemaque Innocent at the Partners In Health hospital in Cange, Haiti, 2004. (Daniel Wallace/St. Petersburg Times )
2004: Paul Farmer examines AIDS patient Thelemaque Innocent at the Partners In Health hospital in Cange, Haiti.

Back in Haiti, Zanmi Lasante’s operation grew, in only a few years, from a one-room clinic to a complete hospital with a nursing school, operating rooms, satellite communications and a blood bank. It serves a community of more than 150,000 people, trains and employs local personnel as community health workers, dispensing food, water, housing assistance, education and other social services. Farmer’s innovative therapies were curing infectious diseases, such as tuberculosis, for a hundredth of the amount that treating the same disease would cost in a U.S. hospital. Farmer’s achievement was recognized by the MacArthur Foundation in 1993 with a $220,000 “genius grant,” which Farmer immediately donated to PIH to start a research program, the Institute for Health and Social Justice.

By the end of the decade, Zanmi Lasante had built schools, houses, communal sanitation and water facilities throughout the central plateau. It had vaccinated all the children in the area, dramatically reducing malnutrition and infant mortality. It had also launched programs for women’s literacy and AIDS prevention. It has been particularly successful in combating the spread of AIDS in Haiti, one of the original flashpoints of the epidemic. By 1999, the rate of HIV transmission from infected mothers to babies in the vicinity of Cange was less than four percent, half the contemporaneous rate in the United States. Zanmi Lasante became a global model for delivering public health services. The World Health Organization adopted its methods for controlling AIDS in over 30 countries.

Pulitzer Prize-winning author Tracy Kidder told the story of Paul Farmer and Partners in Health in his 2003 best-seller Mountains Beyond Mountains.
Tracy Kidder told the story of Paul Farmer and Partners In Health in his bestseller Mountains Beyond Mountains.

In Cange, the organization successfully suppressed an outbreak of drug-resistant typhoid by reforming the water supply. Although tuberculosis (TB) was still the leading cause of adult death in the rest of Haiti, TB fatalities were virtually eliminated in the region served by Zanmi Lasante. Farmer and Zanmi Lasante enjoyed particular success in treating multiple-drug-resistant tuberculosis (MDR-TB), a potent strain of the disease that has evolved, in part, because of the previous misuse of antibiotics in underdeveloped communities. After their success in Haiti, Farmer and PIH were asked to develop community-based health programs in Peru and Russia, when MDR-TB outbreaks appeared there. In Peru, PIH efforts to fight MDR-TB achieved an 80 percent success rate, better than that of U.S. hospitals.

Meanwhile, Paul Farmer was sharing his message in a series of books, including AIDS and Accusation, The Uses of Haiti, Infections and Inequalities and Pathologies of Power. Pulitzer Prize-winning author Tracy Kidder told the story of Paul Farmer and Partners In Health in his 2003 bestseller Mountains Beyond Mountains. Farmer’s work attracted the support of philanthropists, including George Soros and Bill and Melinda Gates. In 2002, PIH received a $13 million grant from the Global Fund for improvements in the Cange complex. In 2005 the William J. Clinton Foundation funded a Partners In Health AIDS program in Rwanda. As of this writing, PIH has projects in Haiti, Lesotho, Malawi, Peru, Russia, Rwanda and the United States, and supports other projects in Mexico and Guatemala.

Dr. Paul Farmer discusses his book "To Repair The World" about the challenges of global poverty and human rights.
In Paul Farmer’s 2013 book To Repair The World, he discusses the challenges of global poverty and human rights.

As Partners In Health has expanded its activities, Paul Farmer spends many of his days flying from country to country, monitoring new programs and raising funds for Partners In Health. The rest of the year, he lives in Boston with his wife, the Haitian-born anthropologist Didi Bertrand, and their three children. He heads the Department of Global Health and Social Medicine at Harvard Medical School, where he is the Presley Professor of Medical Anthropology. In August 2009, it was announced that the United Nations’ Special Envoy to Haiti, former U.S. President William J. Clinton, had selected Dr. Paul Farmer to serve as Deputy Envoy.

Inducted Badge
Inducted in 2009

For nearly 30 years, Paul Farmer has done what others thought impossible, bringing first-rate medical care to the poorest people on Earth. He first traveled to Haiti as a young medical student to volunteer in the most disease-ridden region of the poorest country in the Western Hemisphere. He continued his studies long distance, earning doctorates in both medicine and anthropology while treating more types of illness and injury than most physicians encounter in a lifetime.

He built a world-class medical facility on the central plain of Haiti. To fund his work, he established the Boston-based charity Partners In Health. In Peru, Siberia, Mexico, Guatemala, Rwanda and in Boston’s inner city, he has pioneered a community-based model of health care, and developed revolutionary treatments for AIDS, malaria and multi-drug-resistant tuberculosis.

In his books, such as Pathologies of Power, he denounces the “structural violence” that denies millions the most basic of human rights. “It’s wrong for the destitute sick of the world to die unattended,” he says. “We can change that.”

Watch full interview

You were already in Haiti when you were accepted to Harvard Medical School. How did that come about? Did you already know what you wanted to do when you graduated from college?

Paul Farmer: After I finished at Duke, I thought, “Well, am I gonna have a future in research or in international development work?  Am I going to work in an American city or work abroad?” And I was trying to figure that out, like a lot of people who are 22, 23 are trying to do. And I say to my students, including undergraduates, “Go off and find out.  Don’t try to answer that right when you’re 22.  I didn’t.”  I went from Duke to the University of Pittsburgh and then to Haiti.  And then I went back to Brooklyn.  So I had, in that year after college, I got to try a lot of things and see where I might be most comfortable casting my lot as a physician.  As I said, I knew I wanted to be a physician, and yeah, I applied to Harvard Medical School and one other medical school, because I was interested in medical anthropology, which is a very arcane little field. It’s a narrow strip of scholarly interest in medicine and public health.  So I really wanted to go to Harvard, because there were people there I wanted to work with, and I got that letter when I was in Haiti, in the middle of Central Plateau, which is where I still am working to this day.

Were your plans to stay in Haiti indefinitely after college? You didn’t know if you’d be accepted to medical school.

Paul Farmer: No, it wasn’t open-ended.

I thought it’d be great to learn how to speak Haitian Creole, and it would be very handy to be — if you’re a doctor in the United States on the Eastern seaboard — to get to know Spanish, to get to know Haitian.  It wasn’t my intention to spend a quarter of a century there. I’m headed back there from here, so it’s gonna be more than a quarter of a century.  I think it was the right thing not to have a set plan, and I say this to students all the time.  Why should you know what you’re gonna do when you’re 22 or 23 years old?  You’ve gotta allow yourself to be open to new experiences and to keep on learning all the way.

In Paul Farmer's 2011 book "Haiti After the Earthquake," he explores Haiti's disaster and its attempt to rebuild from the earthquake in January 2010
In Paul Farmer’s 2011 book Haiti After the Earthquake, he explores Haiti’s disaster and its attempt to rebuild from the 2010 earthquake. Farmer brings passion, medical expertise and a long and intimate engagement with Haiti.

When you arrived in rural Haiti, you found people in a desperate state. Did you find they were resigned to the situation?

Paul Farmer: I wouldn’t have put it that way, although other people did. Are Haitians resigned or are they accurate observers of their possibilities? I think back to that particular point in time, say 1983-84. You go into a place, and everything is always dynamic and changing. That doesn’t mean you can see it. We’re doing this interview in South Africa. I don’t know what it felt like to be in South Africa in the ’80s, and there are people right here in this room who do.

Going into Haiti at that time, it wasn’t clear to me how much things were changing and about to change.  So I think people going to Haiti — Americans or people from Europe — and they would say the poor are resigned to their fates.  I might have said that when I was 24, but I learned, a lot later on, that they weren’t resigned to their fates, that there was a power to organize and push for real democratic engagement.  It was very inspiring to me. So if I said that, in 1984 when I was 24 years old, that they were resigned, that would have, I think, been an error.  I may have said it, but that would have been wrong.  Again, you learn things.  You keep staying engaged. I wouldn’t have thought, for example, that the country of Rwanda could make so much progress in the decade following the genocide in 1994, and yet they have.  You know, it’s stable, orderly, growing, the economy is prospering.  There’s a commitment to social services like health and education. I don’t think that anyone there in 1995, for example, would have predicted that.  So I think it’s wise to be humble about what’s happening in the dynamic of a place.  But I may have said that when I was 24.  I hope not, but again I have to look back.

Initially you went to a hospital in Haiti, in between medical school. Can you tell us about the experience there, and why the system either worked or didn’t work?

Paul Farmer: Yeah. I went to a lot of healthcare infrastructure in that first year.

I went to clinics, I went to mobile clinics, I went to rally posts, I went to hospitals. I went to well-known hospitals, less well-known hospitals.  It was an eye-opener.  It was just very disturbing. You know, the quality, and some of them are well funded, some of them are underfunded, some of them were well managed.  But I understood how much the odds are stacked against poor people in that year.  Again, looking back, following the lines of your interview, in university, in college, you can read about all these things, and I think it’s really important to do that. But when you can draw on a lot of reading and studying and hard work about a place, say Haiti for example, and then you head off to that place and actually experience it, then you have a whole different level of learning and experience. And that’s what happened to me is, I’d read about it, and I’d try to do due diligence and be assiduous in reading.  But then to see it in all these different settings.  As I said, clinic, rally post, hospital, it was very mediocre for poor people at best.

So that was the general experience. Wow, the quality of services — even those set up by people of goodwill, some of them I still work with today — they still were lousy medical services. It’s hard to say that. It’s not fun. Maybe this is some advice, too, for people who might look at a video like this.

Keys to success — Perseverance

It’s very easy to criticize projects like this.  It’s very easy to go in, as a privileged person from, say, an American university, and go in and say, “Wow, this is really poor quality care,” or very poor quality services.  That may be true, and it’s easy to say, but it’s not always the best way to engage.  So what I tried to do is to stay engaged, in spite of the fact that the quality of services was terrible.  You know? So that diagnosis is easy. Then what is the prescription?  What do you do to really engage to improve things?  You know, one of the things that I can look back at with some pride and say is, “Well, at least we stuck with it.”  So 25 years later, we’re still trying to improve and expand.  We still have a long way to go, but that’s the trick is persistence, staying engaged. You know, people say to me, “What’s the secret?”  I would say that’s the real secret, is — it’s not always a big idea or some innovation.  I’ll make this point tonight in my remarks, because sometimes what’s innovative and what’s entrepreneurial is just staying engaged with something that’s difficult.   You know, just sticking with a tough problem.  There are people in this country, for example, who are, say, providing medical services in townships.  You know, if they’re looking for some magic recipe to radically improve health outcomes, they’re not gonna find them.  It’s really persistent engagement, and fighting for basic services like electricity and water and housing and primary healthcare, and that’s what they call in medicine — they call that scut work.  That’s just drudgery.  But the real innovation sometimes is just sticking with it.

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After your first year in Haiti, what did you believe was needed most?

Paul Farmer: If you start in a squatter settlement, if you start up in a place like Cange, there’s no school.  There was the beginning of a school when I got there.  There was a school, but initially that school was outside, under a mango tree, with a banana-thatched roof.  So that wasn’t considered a worthy school.  I was working with this Episcopal priest.  I still work with him now all these years later.  So there wasn’t a modern school.  There wasn’t a clinic.  There wasn’t a hospital.  There wasn’t water.  There wasn’t electricity.  There wasn’t primary healthcare.  There wasn’t community health workers. There weren’t trained teachers.  So all those things would fit in the — and there weren’t jobs.  That’s another — people need jobs, as I was saying earlier.  You talked about disempowering a community.  That word empowerment has been much abused.  We misuse it all the time. To me, I would use it the way you did, is that people need jobs and livelihoods to be empowered, to be able to take care of themselves.  So in that particular setting, as in much of rural Haiti, everything remained to be done.

While mothers comfort their children, Dr, Farmer goes over the case load in the pediatric ward at Rwinkwavu Hospital in Rwanda. (Eric Neudel for The Boston Globe)
Dr. Paul Farmer in the pediatric ward at Rwinkwavu Hospital in Rwanda, where mothers comfort their children.

What about a medical clinic?

Paul Farmer: There wasn’t one. There was no clinic. But remember, I’d already been to many clinics and hospitals that were terrible. So that wasn’t a good model. The one I saw, it was not inspiring. It took me many years to understand, and remember this is not me. You’re asking about my story, but I worked with first scores, and then hundreds, and then eventually thousands of people in Haiti, almost all of them Haitians. And the initial community health workers who we recruited and trained together in 1984, they’re all still working together. We still work together.

When you arrived in Central Plateau of Haiti, they didn’t have a blood bank. There had been no immunizations.

Paul Farmer: No, it didn’t have a blood bank. Maybe it did on paper, but if you went, there was no blood.

Keys to success — Perseverance

It’s hard to have a blood bank without blood.  It’s hard to have a blood bank without electricity and lab techs, et cetera. But again, it’s easy to make that diagnosis, and easy to rail against institutions, including the Red Cross.  But it’s much better to start working with them to build blood banks, and that takes a lot of time.  But it’s certainly not impossible.  (If we can) put someone on the moon, we can certainly put in better blood banking. And that didn’t happen.  I think it happens, again, with persistence.  It’s not some innovation, or the really entrepreneurial thing. This is the point I’ll make tonight in my comments, is the really entrepreneurial thing is for someone just to stick it out and serve the poor. Then you learn things.  Now you don’t want to keep re-inventing the wheel.  So if we learn something in Haiti that’s useful in Boston, we need to make sure and share that information.  If we learn something in Rwanda that’s useful in Haiti, we need to get it back there. And that’s another problem, I think, in development work and NGO work, is there’s a lack of coordination and sharing of information, experience.  But again, these are not problems that are insuperable.  That’s why you guys have your website, so you can reach out to lots of people who you’re not actually ever gonna meet. We need to harness those technologies as well.