Paul Farmer on my mind

Paul Farmer visiting Bayalpata Hospital in Achham run by Nyaya Health Nepal on its third anniversary in 2012. Photo: DEEPAK BISTA/NHN

When we were in 11th grade, my friends and I wanted to bring healthcare services to an impoverished village near Pokhara, my hometown. The best solution we could imagine was what is colloquially called a ‘health camp’: show up in a village with a doctor and some medications, go through hundreds of patients in a few hours, and leave. 

We believed that since doctors and medications were expensive, and the poor could not pay, a health camp was the best we could do.

In college, my anthropology professor introduced me to the work and writings of the physician and medical anthropologist Paul Farmer, who described relegating the poor to such meager services as, quite simply, a ‘failure of imagination’.

His influence transformed my thinking regarding the most vexing problems in global health: the poor are not to blame for their economic condition and its attendant health challenges. Rather, the blame falls on our collective lack of imagination, which is rooted in, to borrow another phrase from Paul, ‘the idea that some lives matter less’. And that is how Paul began to live in my mind, as he did for thousands of others interested in healthcare. 

Paul provided the requisite vocabulary to make sense of deep inequities, and he inspired with his actions. He and his team at the non-profit, Partners in Health, have brought life-saving healthcare services to indigent populations by supporting 230 healthcare facilities in 12 countries. 

His work inspired me to go to medical school and co-found the non-profit organization Possible with other like-minded medical students, all of us committed to expanding high quality healthcare in rural Nepal. 

We had no track record, credibility, or adequate funding but Paul supported us. Graciously, he joined our Board, advised and mentored us, helped make connections, and let us leverage his credibility to raise funds. On the Partners in Health website, he included Possible as an organisation expanding the mission for high quality care for the poor. 

He shared his expansive platform by including Possible’s work alongside his. His generosity could have cut into his own fundraising efforts, but he always rejected the belief that the pie is small, and we should fight over it. He inspired us to fight for a bigger pie, and he willed that world into existence.

Back in Nepal, we began with a small clinic in Achham, where 250,000 people had no access to even a single doctor. We faced many detractors, and sometimes we doubted ourselves. But his words, spoken clearly and earnestly, helped us form our moral compass and inspired a determination that would not countenance failure. 

Because more funding was available for HIV programs, many advised us to open an HIV clinic, but we knew that Achham needed comprehensive services beyond strictly HIV care. Well-meaning supporters lamented, sounding much as my friends and I had in high school, that the best we could do was a series of health camps. Surely, they fretted, there was no money for anything long-term. 

People seemed to have an unspoken collective agreement that when it comes to serving the poor, there are not enough resources. Paul had a phrase to describe this social myth: ‘socialisation for scarcity’. The reality is, he taught, there are enough resources in the world to provide high-quality health services to every poor person, but we fail to make this a reality. We back away from this challenge, simply because we assume it is not possible. 

A well-wisher suggested that we build something in Kathmandu rather than in rural Nepal because people in Kathmandu can pay for services. This time, we thought of another phrase that Paul popularised as a reminder that the system needs to be built to serve those with the greatest needs. He called this ‘a preferential option for the poor’. 

In 2009, we established Nyaya Health Nepal, a Nepal-based sister organisation to Possible, and collaborated with the Nepal government to expand to Bayalpata Hospital. In 2012, Paul visited Bayalpata, rounding on patients with the local clinicians, teaching and inspiring with his intellect and humor. He expressed genuine admiration towards the healthcare workers living and serving in rural Nepal. 

He somehow managed to express more gratitude than he received, in a way most people would not expect from someone with his level of accomplishment. After the 2015 earthquake, our team expanded to Dolakha, and at its peak, was overseeing three permanent hospitals with 350 staff: a long way from sporadic health camps.

A few years ago, I was in a small global health conference and we were waiting for Paul Farmer to speak. As most busy speakers do, we expected him to sweep in, give a talk, and jet off to the next event. I felt a tap on my shoulder. It was Paul. I was surprised to see him with the audience. We hugged. He asked me how I was doing and wanted to know how he could help with our work in Nepal. I thanked him for having highlighted the importance of mental health in high-profile global health meetings. 

He thanked me for working in mental health, a persistently ignored area. He then walked around the room, surprising and personally checking in with several people who were working in different parts of the world. Later, the organisers told me that Paul had asked for the list of attendees so he could check in with the people he knew were doing similar work in global health. 

He did not need to do any of this. He had a way of being present with you, listening, inspiring, and building solidarity for his commitment to the most vulnerable.

On 21 February, 2022, Paul passed away in his sleep in Rwanda, where he had been teaching and seeing patients at the University of Global Health Equity, a world-class university that he helped to establish. He was 62. He left behind three children and his wife, Didi Bertrand Farmer, a medical anthropologist from Haiti. 

As Bill Gates wrote recently, the void Paul left cannot be filled by anyone. But I know that although he is gone, his work will continue through how he influenced us, through his incisive writing and inspiring legacy. He will continue to live in my mind, urging us not to succumb to failures of imagination, and instead to fight against socialisation for scarcity to boldly build a preferential option for the poor.

Bibhav Acharya, MD is a psychiatrist, an Associate Professor at University of California San Francisco, and co-founder of Possible, a nonprofit organization that has been working to improve health care in Nepal since 2007.


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