Remembering Paul Farmer, Pioneer In Global Public Health

Yesterday marked two years since Paul Farmer’s passing in Rwanda at the age of 62. Farmer, a physician-anthropologist, left behind a remarkable legacy across multiple fields, including infectious diseases, medical anthropology and global public health.

The Harvard Gazette reported that in November of last year Harvard Medical School held a symposium, which can be viewed here, to honor Farmer and reflect on the global influence of his efforts.

Farmer’s formidable career began when he co-founded Partners In Health with the mission to provide high quality care to impoverished patients and those living in remote areas. Since the early 1990s, Partners in Health expanded to countries in Africa and Latin America.

Madhukar Pai, Canada research chair of epidemiology and global health at McGill University, noted the profound impact Farmer had around the world. In addition to starting hospitals in Rwanda and Haiti, Farmer helped bring lifesaving HIV and tuberculosis drugs to patients in developing nations through community-based care initiatives.

Farmer embodied the spirit of a humanized global public health. While his was an altruistic vision, he believed that what he was doing was mutually beneficial to poor and rich countries alike.

In 2020 and 2021, Farmer was involved in Covid-19-related work in the U.S. and overseas. And as he suggested, if we learned anything from the Covid-19 pandemic it’s that the phrase “we are all in this together” isn’t an empty slogan. By nature, an infectious disease pandemic connects us all as a global community. Viruses transmit from person to person, and then by way of international travel they go from one country to another. No country or region is immune.

Arthur Kleinman, Harvard University professor of medical anthropology, psychiatry and global public health and social medicine, considered Farmer a mentor. What stood out to Kleinman was Farmer’s dedication to patient-centered care under the most urgent of circumstances, wherever he set foot. In an article posted yesterday, Kleinman wrote that Farmer taught that the “moral responsibility of the healer is to step inside patients’ experiences and accompany them through the worst moments with empathy and expertise, compassion and care.”

From Tropical to Global Public Health

Originally, global public health was called “tropical health.” To this day, the naming of certain entities retains vestiges of the past: For example, the London School of Hygiene and Tropical Medicine. Tropical heath, however, connotes the colonial context of healthcare for the subjects of Western rulers. As European powers eventually left their colonies, the nomenclature of the field changed to “international health” and then over time to “global health.”

Irrespective of the names given, people in the field have often viewed their work from a perspective of constraint: With limited resources, what is the most good we can do? But Farmer didn’t share this utilitarian view. Rather, he asked, what’s possible, given the local, “biosocial” context, which accounts for the social, economic and political dimensions of health, illness, treatment, and healing? Farmer pushed boundaries and didn’t accept scarcity of resources as a reason that the poorest could not receive technologically adequate healthcare. Repeatedly, and in multiple under-resourced settings, he demonstrated that the necessary medical technologies could often be found and mobilized.

Nevertheless, it was clear to him newer and better medicines were needed to combat diseases that predominantly affect the developing world. Farmer urged more research and development targeting the deadliest infections, including HIV/AIDS, malaria and TB, but also neglected tropical diseases such as cholera, lymphatic filariasis and river blindness.

Severely limited commercial prospects in developing nations initially hampered R&D funding from flowing towards the “big three”—HIV/AIDS, malaria and TB—and NTDs. Twenty years ago, this gradually began to change. Governments in wealthy nations started channeling more resources towards these diseases, in part by deploying regulatory incentives, such as tax credits and priority review vouchers, to incentivize R&D funding. Lastly, philanthropic entities, such as the Bill & Melinda Gates Foundation, poured hundreds of millions of dollars into NTD projects. At the same time, they established public-private partnerships, such as the Medicines for Malaria Venture, to address specific disease areas.

What ensured was that drug development targeting HIV/AIDS, malaria, and TB received comparatively large sums of R&D money And in the 2000s, taking a cue from the work of Farmer and others, Novartis realized that simply donating the anti-malarial Coartem (artemether/lumefantrine) wouldn’t be sufficient. There had to be boots on the ground, so to speak, to get appropriately formulated medicines to where they’re needed most.

Novartis and the Medicines for Malaria Venture worked in partnership to develop Coartem Dispersible, a new formulation designed specifically to meet the specific needs of children with malaria. Additionally, Novartis partnered with the World Health Organization to deliver hundreds of millions of Coartem treatments (75% with the pediatric formulation; 25% for adults) to malaria patients in developing countries, supported by local supply and logistics, training and educational programs.

Four years ago, Farmer wrote that the “establishment of the Bill & Melinda Gates Foundation, which invested in discovery and development, and the President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which invested in delivery, offers a blueprint for global health equity. Whether we look at cholera or lymphatic filariasis or malaria, the roadmap for the future of tropical medicine and hygiene is the same: Scientific discovery linked to product development and, most importantly, to an equitable delivery strategy.”

Farmer left behind a “generational legacy” that forever changed the way we view global public health. It was his foresight which helped alter the top-down approach of healthcare assistance to one of localized aid, working with local governments, agencies, and medical professionals to deliver healthcare to the world’s poorest places.