The Life of One Patient – Memories of Dr. Paul Farmer (1959-2022)

Nathanael E. Hughes, MPH, MPP, MPhil

Senior Director, Business Development at Peachtree Bioresearch Solutions, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA; E-mail: natehughes73@gmail.com

“It always seems impossible until it’s done”.
– Nelson Mandela

“Christians have not done enough in this area of conversion to the neighbor, to social justice, to history. They have not perceived clearly enough yet that to know God is to do justice. They have yet to tread the path that will lead them to seek effectively the peace of the Lord in the heart of social struggle”.

– Gustavo Gutierrez

Doctor Paul Edward Farmer passed away on 21 February, 2022 of an acute cardiac event in his sleep at University of Global Health Equity (UGHE) in Butaro, Rwanda, an institution which he helped found. Launched in September 2015, UGHE is a new kind of university focused on delivering the highest quality of health care by addressing the critical social and systemic forces causing inequities and inefficiencies in health care delivery. That week, Paul had been teaching and treating sick patients, one of which passed away from complications of late-stage acquired immune deficiency syndrome (AIDS), a young man in his mid-thirty’s whom Paul had cancelled a trip to Sierra Leone for. He was devastated when he lost the patient, after trying out different life-saving therapies, interventions, and possible hospital transfers to save the life of one patient. A few days later, exhausted and in bed to rest for only a few hours, the man who had the world’s biggest heart, himself died away of a cardiac event. Part of me thinks that Paul internalized the pain his one patient was suffering.

Despite the life of prodigious, accomplished achievements – a MacArthur “genius” award in 1993, member of the Academy of Arts and Sciences and the Institute of Medicine of the National Academy of Sciences, from which he was the recipient of the 2018 Public Welfare Award, co-founder and self-described “chief strategist” (he gleefully commented) of Partners In Health (PIH), Kolokotrones University professor at Harvard Medical School, comfortably wrestling between the foundations of power and the “poorest of the poor”, Paul lived his life in contrast.

Here are just a few metrics from PIH and what the nonprofit has accomplished since its inception in 1987: 2.8 million outpatient visits in supported clinics, 2.1 million women’s health checkups around the world and over 2.1 million home visits conducted by community health workers.

Paul and I were so close. I imagine part of it was his trying to grapple with being a medical anthropologist and a practicing physician, having left his family so many times to be in the field with his patients. He understood that I myself was a child who grew up as a third culture kid in the field of anthropology, and during my childhood and adolescent years, I was left with my sisters in Northeast Brazilian pharmacies hearing about the maladies of poor peasants while my mother conducted social epidemiological research for her masterpiece “Death Without Weeping”, a book Paul often told me was one of his favorite ethnographies and which had an immense influence on his own writing in Haiti, and later Rwanda.

Another aspect of our over 30-year friendship was that I knew Paul since he was a medical student. I saw him develop his own brand of activism, and I while my mom had mentored him at a critical juncture in his life, so had he played that role for me in my own development, which ultimately led me to the field of global public health.

He wanted to know that he was a good father and was it OK that his priority was to the poor, the life of one patient. His daughter, Katherine, during a ceremony at Trinity Church in Boston on March 12th, 2022, described perhaps my favorite story (and there are so many) of Paul. During the last couple of years amid the coronavirus disease (COVID) pandemic, Paul spent more time in Miami with his three children and wife Didi Bertrand and had an abundant garden outside which he spent several hours working on. At one point working in the garden, he turned to Katherine with tears welled up in his eyes, and almost apologetically said, “I had to do this work. I had to do it. And if I had the chance to do it all over again, I would have done the same thing”. Kathrine embraced her father. She understood, and she was OK with it. He always led with love, he led with compassion.

I wanted to make sure that I sent some memories from Paul’s teachers, mentors, and friends, to capture who he was – and how he will be remembered. All of us agree, that we must do the work to bring good trouble in medicine and medical anthropology to light.

“Dear Arachu and friends

We must all have so many memories of Paul. I first met Paul when he was an eager undergraduate at Duke University and then much later as anthropologist-physician at Harvard. (All Duke flags on campus will be lowered through Wednesday in his honor.) Then of course Paul went to Haiti. One day in Berkeley Paul showed up to my crowded house asking for a couch to sleep on. The next morning Paul was in the kitchen washing dishes with our former Gov. Jerry Brown, then Mayor of Oakland. At one point we bumped into each other during the end of Cuba’s human immunodeficiency virus (HIV)/AIDS sanatorium.

Paul inspired so many people and organizations to fight epidemics, social and political injustice, and the basic needs of the world’s sick-poor. He argued for a political economy of death counts (à la German anthropologist, Rudolf Virchow). As a physician-theologian, Farmer had a unique ability to capture the embodiment of institutionalized violence and suffering. In addition to fighting the bureaucratic global international health regime Paul carved out time to heal the sick. His double consciousness as a physician-anthropologist, a policy maker and a healer, an activist and a theologian, Paul was able to work between his philosophical critical thinking and his feet-on-the-ground ‘being there’ anthropologist. At times there was a certain world-weariness as he made his back through capitalist foundations and the everyday sickness of needy bodies, just as he was impatient with medical anthropologists. He wanted more, much more from us. I remember Paul saying that he refused to listen to one more Haitian story of ‘sorcery-sent’ illness when it was ‘for-profit medicine’ that was to blame for the dead.

With tears and love”,
Nancy

Nancy Scheper-Hughes, Chancellor’s Professor Emerita
Department of Anthropology, University of California Berkeley

“Dear Nancy and all,

Thank you for sharing these wonderful words…My own friendship with Paul happened around our mutual admiration for Cuban public health and one of my other heroes and dear friend, Jorge Pérez, copied here too. Paul was so gracious that when we decided to make the film SALUD! he was eager to share his thoughts on film and was a major influence in turning the documentary from a feature on Cuba’s international health teams into a much deeper look at the reasons why poor people the world over don’t have access to what makes them healthy, including decent public health systems. As you all know, Paul slept very little–his work, his patients, his writing, and activism all-consuming. But when he arrived in Cuba, as Tracy Kidder described in his book: “When we got to our hotel, Farmer said, ‘I can sleep here. Everyone here has a doctor. ´ He lay down on his bed and within a few minutes he was asleep….”

Rest in power, dear Paul. We need to do so much more to live up to your legacy.

Warm regards to everyone and un abrazo”,

Gail Reed, International Director of Medical Education Cooperation with Cuba (MEDICC)

“He was so admirable a human being in so many ways. And the outpouring of emotion for him almost everywhere speaks to his true place at the moral core of humanitarianism, global health, social medicine. medical anthropology, infectious disease research and practice and more. As he said in a message two days before he died, he was my symbolic son, and the tragic irony of history is that he pre- deceased his mentors. He influenced me so very much and I loved him. it was a 40-year relationship, and I had the full measure of Paul, so extraordinary were his virtues, his vision, his down to earth humanity, and the lightness of being he animated. Paul is irreplaceable, but we will all struggle to pick up the burden and continue his work and your work to repair the world. Because you, Nancy Scheper-Hughes, modeled for him productive ways of destabilizing the status quo and reframing the future to privilege the wretched of the earth. Blessings in his memory on all of us who care”.

-Arthur Kleinman, PhD advisor, and Professor of Medical Anthropology,
Department of Global Health and Social Medicine, Harvard University

“Paul gave everything – everything – to others. Life was not about what he could do for himself. It was about what he could do for others, and in that, life’s successes were measured. When I told him I was writing about trade unions for my undergraduate honors thesis at University of California (UC), Berkeley, USA he chided me for thinking so linearly about institutions and how they relate to the very worst off in society (reminding me of the veil of ignorance theory by late Harvard philosopher John Rawls). He said, “Trade unions represent trade union interests. Never forget the poorest of the poor” he quipped. Paul Farmer described himself as a “cracker from Florida””.

He used to come up to University of North Carolina (UNC) from neighboring Duke and fell in love with the field of medical anthropology while auditing my mom’s classes. He also fell in love with Haiti then and decided to go down there and volunteer. If Paul were not a physician-medical anthropologist, perhaps he would have been a missionary, a saint, maybe even a Chief Executive Officer (CEO) in a boardroom. He certainly had the gravitas and focus for that. Quiet in a room, you could always feel his presence, his power.

When I saw him this past November 2021, I was lucky enough to joke about the old times in North Carolina (NC), agree to an imminent trip to West Africa, talk about his upbringing, and keep it light in the face of global epidemics (and a pandemic). I told him I had lost my iPhone in a Harvard cab, and he smiled, “Isn’t that great though, to be without it?” The last meeting, I reminded him what our family likes to call him, “Saint Paul”. He beamed. His smile was infectious.

When I was at a low point in my life in 2010, I went out to Boston to spend time at PIH and seek solace, a quiet guidance from him since I have known him since I was a kid in North Carolina. Lost, I found my way, since he recommended an Master of Public Health (MPH) program and set up a fortuitous meeting with his PhD advisor, Dr. Arthur Kleinman at the Asian Center at Harvard.

One time in 2017, I had asked his assistant, Katherine, to set up a meeting in downtown Boston. “Paul is running late and had to see patients in Haiti. But he is on the next flight to see you”. I met Paul in a downtown restaurant, where he plotted down with a bag full of stethoscopes and was in route later to Amsterdam and then West Africa, where we had been discussing a possible trip together to see patients. He wanted to know how my nascent engagement was going at the time. He often quoted Gustavo Gutierrez, the liberation theologian. Paul and I talked fondly of our mutual friend, Tolbert Nyenswah, who was Liberia’s deputy minister of health for disease surveillance and epidemic control from 2015-2017, during the Ebola crisis.

In 2021, when another colleague asked if Paul could speak for United States Agency for International Development (USAID) in Washington, D.C., he cleared his schedule and made it happen.

More than anyone, he reminded me that social justice is in my family’s deoxyribonucleic acid (DNA). “You can’t avoid it” he would say. He made you feel like the most important person in the room and often stared through you – directly and without distraction (a technique he invariably picked up from Bill Clinton). Paul was wickedly funny, engaging storyteller, genuine, kind, humble, warm, irreverent, perennially optimistic in the face of an unfair world, vivacious, raw, attentive, thoughtful, and decent. Moreover, a decent soul who walked this earth dedicated to a less crooked world, never losing that faith, a faith rooted in humanitarian ethics. “The idea that some lives matter less is the root of all that is wrong with this world”. Like Tracy Kidder, the author of Paul’s biography, “Mountains Beyond Mountains”, I also like to think that he died happy, although I know he also carried the pain of the life his one patient he could not save to bed. Again, in his world of contradictions, he was straddling the world of suffering and the world of hope. Rest in Peace, dear brother.

-Nate Hughes, Senior Director, Business Development at Peachtree Bioresearch Solutions