Becoming Farmers (Part II)
Tout Moun Se Moun
We have just returned home from Lesotho after six months working with Partners In Health to address MDR-TB and experiencing life in this remarkable mountain kingdom. Reflecting further on that experience brings us to the second in a two part series on the work and philosophy of Paul Farmer and Partners In Health, and what that example means for those inspired by it.
Tout Moun Se Moun. The philosophy that Farmer brought to his medical practice and to the foundation of PIH can be summed up with the Haitian Creole saying “Tout Moun Se Moun.” Literally, “every person is a person.” It’s the simple message that at the life of every human being is as important as the life of any other. While that may sound obvious, the unequal and inequitable distribution of what’s needed to live a healthy life show that our world today, and the political choices that shape it, don’t reflect that value. It’s radical in the true sense, a return to a root core belief that changes every decision to follow.
“If access to health care is considered a human right, who is considered human enough to have that right?” Paul Farmer, Pathologies of Power
Put another way, you have Paul Farmer’s most famous quote: the idea that some lives matter less than others is the root of all that’s wrong with the world.
Structural violence
Another term for “all that’s wrong with the world” is structural violence. Farmer describes this as “a broad rubric that includes a host of offensives against human dignity: extreme and relative poverty, social inequalities ranging from racism to gender inequality, and the more spectacular forms of violence that are uncontestably human rights abuses.”1 Political systems, class structures and global markets conspire, intentionally or not, to keep people in poverty: near to the causes of illness, and far from the cures. Any serious effort to counter the world’s greatest health challenges must go beyond providing great care to challenge the structures that enable a world where, as Sir Michael Marmot tells us, “social inequalities are killing on a grand scale.”
Preferential option for the poor
The mission statement of PIH is “to provide a preferential option for the poor in health care.” This phrase, like the accompaniment model, are borrowed from liberation theology, a branch of social justice-oriented Catholicism that emerged in Latin America in the 1960s. Here is where Paul Farmer’s work has been perhaps the most courageous. In the secular world of medical research and international aid, Farmer was fearlessly open about a faith that challenged more than it consoled.
“Matthew twenty-five,” said Farmer. “Inasmuch as you have done it unto the least of these my brethren, you have done it unto me.” He went on, paraphrasing, “When I was hungry, you fed me. When I was thirsty, you gave me something to drink. When I was a stranger, you took me in. When I was naked, you gave me clothes. When I was sick, when I was in prison, you visited me. Then it says, Inasmuch as you did it not, you’re screwed.” - Mountains Beyond Mountains
Liberation theology challenged the church to direct its outreach to the poorest of the poor, and to advocate politically for them to be raised out of poverty. It’s a belief that Jesus’ message of salvation is relevant in this world, not only the next, with “whatsoever you do to the least of my brother, that you do unto me”2 the guiding principle.
Farmer and PIH extended this idea into their vision of health care, arguing those who need care the most should get the best care. Rather than scraps and neglect sold as sustainability, it’s the poor and underserved of the world who have the greatest claim to the benefits of modern medical science. Along with working upstream to help people get out of poverty, we should be fighting to get care to the hardest-to-reach places and the people most in need.
Any serious examination of epidemic disease has always shown that microbes also make a preferential option for the poor. But medicine and its practitioners, even in public health, do so all too rarely. Imagine how much unnecessary suffering we might collectively avert if our health care and educational systems, foundations, and nongovernmental organizations genuinely made a preferential option for the poor?
Paul Farmer, How Liberation Theology Can Inform Public Health
Failure of imagination
Faced with this profound call for justice in an unfair world, Farmer fought against narrow notions of sustainability. Too often, when it comes to treatment of illness in low-income countries, people argue for appropriate technology. This is code for giving substandard care under the guise of sustainability. The most perverse examples of this were the arguments in the 1990s and early 2000s that it was impossible to treat HIV in Africa and we needed to focus exclusively on prevention. Ignoring the fact that this meant standing by while millions of people died painful and preventable deaths, it also missed the point of prevention entirely. If you don’t treat HIV, or TB, or any other number of infectious diseases, you ensure their propagation. What’s truly unsustainable is prevention without treatment.
Why do we have an extensive literature on why it is not “cost- effective” or “feasible” (or “sustainable” or “appropriate technology”) to treat poor people who have complicated diseases? - Paul Farmer, Pathologies of Power
Saying it’s simply too difficult or too expensive to treat disease is a failure to recognize just how expensive and difficult life becomes when disease runs rampant. The social and economic costs of HIV or malaria or cancer are incalculable. The decision to look away rather than innovating new solutions is the failure of imagination that Farmer decried and is rooted in a devaluation of certain human lives. Addressing the gross health inequities in the world demands a creativity that refuses to accept avoidable illness and death as “just the way things are” It demands an invitation to what Farmer called “the House of Yes” in a world where too often the first answer to a cry for help is a list of excuses why it isn’t possible to care for those who need it most.
"I feel it's part of my job to make the problems of the poor compelling. It's only through a failure of imagination that people turn away. The poor are doing their job — they're shouting as loud as they can. It's we who can't hear them. - Paul Farmer, PBS interview.
The Long Defeat
The final concept I want to talk about from Farmer’s work is that of the long defeat. I wrote the following in A Healthy Future:
I’ve been thinking a lot about Farmer since he died suddenly in Rwanda in 2022 at the age of sixty-two. No contemporary physician can compare with the influence Paul Farmer has had on a generation of doctors. In his seminal 2003 book, Pathologies of Power, he wrote: “It took me a relatively short time in Haiti to discover that I could never serve as a dispassionate reporter or chronicler of misery. I am only on the side of the destitute sick and have never sought to represent myself as some sort of neutral party.”3 Reading his articulation of structural violence in Haiti and Peru helped give me the vocabulary to describe what I was seeing in Mozambique or inner-city Saskatoon. His writing on the connection between liberation theology and social medicine spoke directly to my reasons for becoming a doctor.
Farmer used to speak of the “long defeat” of siding with those whose lives are stacked against them. This is inherent in the kind of medicine he practised, a preferential option for the poor against the crushing inequities within countries and between the poorest countries and the wealthiest. He won a lot – his work and the work of PIH have saved millions of lives – but it was still the long defeat. To extend the analogy, it’s a concept inherent to medicine as well: no matter how good your treatment, all of your patients will die. As Dr. Rieux admitted in The Plague, all our victories against illness and death are temporary, “but that is not a reason to give up the struggle.”19
Farmer was never a politician, but his work and writing were deeply political. Politics, too, is a game of the long defeat. Win or lose elections, the change you hope to make will always be receding. For me, the experience of elected life was all a part of the long defeat, and believing that, because the lives of human beings matter, it’s still worth fighting for every win you can even when the ultimate outcome is certain.
Despite acknowledging the inevitability of defeat, this approach is anything but defeatist. His was ultimately a vision of hope for a better, healthier world.
“When you settle on a problem, devote the resources to it and have at least some ability to incorporate new information, every time, it gets better. I don’t have any experience, anywhere, where you just apply yourself, along with others, and then do not see progress.”
Paul Farmer, Time Interview
The Harvest Is Plentiful
When introducing Farmer for an address to the Harvard Kennedy School in 2011, dean David Ellwood told the audience, “no matter what you do, and no matter how hard you work, think about Paul Farmer as a model of someone that we can aim for.…I aspire for all of you, as I aspire for all of us, the chance to be Paul Farmer.”
In contrast, there was apparently once a sign at PIH headquarters that said “If Paul Farmer is the model we’re golden.” Only golden was crossed out and replace by “f**’d,” the message being that no one can repeat what Farmer has done. As Bill Gates said, “there will never be another Paul Farmer.” Anyone who tries to replicate his life or impact will not only fall short, but likely hurt themselves and others along the way.
That much is obvious, but when walking in his literal footsteps, it’s impossible not to ask whether you’re following in metaphorical ones as well. It’s only natural to compare one’s own willingness and ability to serve with such a remarkable role model, to aspire in the way Ellwood urged the HKS students to aspire.
Psychiatrist and medical anthropologist Dr. Arthur Kleinman, himself a mentor of Farmer’s, wrote recently about this dilemma. “I have spoken with several of Paul's former students and coworkers who were drawn by his example into global health work in some of the same desperate settings. They all said that his perseverance motivated them to do the same, but inevitably realized that the scope and scale of his work could not be replicated. Nonetheless, because of his example, they kept trying.
The point is not to become Paul Farmer. The point is for each of us to find our own selves as healers at some point along the astonishing trajectory that he set out. Our capacities will vary. It is about making the radical effort that matters and will continue to matter for each of us who define purpose in our lives through seeking to do the hard work of global health delivery.”
There will never be another Dr. Paul Farmer. We can’t and shouldn’t try to become Paul Farmer’s, but we can each become farmers in our own way. As one of our PIH colleagues reminded us recently, “the harvest is plentiful, but the workers are few.”4
Just as farmers take some of this year’s harvest to seed next year’s crops, the ideas behind his work can inform each new effort to address health inequities. We can take the best of his example and the PIH model and use them to guide us in our own fields, cultivating a practice of compassionate care for human health and reaping the quiet rewards of service that makes a difference.
Paul Farmer, Pathologies of Power.
Matthew 25:40
Paul Farmer, Mountains Beyond Mountains.
Matthew 9:37
A nice read today about the guy that inspires and motivates the guy that inspires and motivates me.
Thanks Ryan.
Keep on rockin'.