Think globally, act locally, is a maxim Dr Paul Edward Farmer, who died suddenly at the age of 62, fully embodied, except that his locale was the entire globe.
For anyone who may not have known him, the first reactions to the shock of his death, said much about the nature of the man.
To most, the first they heard of the news was in a written statement, from Dr Agnes Binagwaho, Vice Chancellor of the University of Global Health Equity (UGHE) where Paul Farmer was Chancellor, and taught.
The statement, barely able to contain the writer’s emotion, told “dear UGHE family” that “today marks one of the saddest days for all of us…it is with our deepest sorrow that we inform you that our beloved Chancellor, the founder of PHI (Partners In Health), and the inspiration for most of us at UGHE, Professor Paul Farmer, has passed away, peacefully in his bed…a life so beautifully lived deserves to be beautifully remembered…” The final encouraging words in the statement showed what he meant to everyone, at “UGHE family.” Clearly aware of how hard, the news would hit them, the statement encouraged them to “stay strong.”
As the news spread wider, tributes begun to pour in from people of all walks of life. They were led by President Kagame.
Never one to miss an opportunity to encourage anyone he believes would be an asset to his country, the head of state will almost certainly have played a major role, in bringing Farmer to Rwanda. Over the years, an intimate friendship would grow, between the two men, as well as their families.
“It is hard to find the words to express the sad news of the passing of Paul Farmer – the person, the doctor, the philanthropist. He combined many things hard to find in one person. The weight of his loss is in many ways personal, to the country of Rwanda (which he loved and to which he contributed so much, during its reconstruction), to my family, and to myself. I know there are many who feel this in Africa and beyond” President Kagame tweeted, “My deepest condolences to Didi, his wife, their children, family and friends.”
Around the world, still mourn Farmer, as for a loved one. A quietly spoken, self effacing man, Farmer nevertheless seemed to be the centre, around which many orbited. The words, love, a giant, come unbid from almost every grieving message.
From politicians, like former American President, Bill Clinton, to Hollywood stars, like Edward Norton, and Mia Farrow, to philanthropists, Bill and Melinda Gates, all speak of their sadness at the loss of a man they admired, yes, but first and foremost, one for whom they cared deeply, and loved.
“I am heart broken that my teacher, mentor, and friend Paul Farmer is gone” tweeted Melinda Gates, he taught me how to listen – really listen – instead of charging in with my own solution. He showed me how to channel my anger about the barriers that hold people back, into relentlessness and optimism…I will miss my dear friend and continue to be inspired by him every day.”
Similar sentiment, from USAID Administrator, Samantha Power. “Paul Farmer gave everything – everything to others. He saw the worst, and yet did all he could to bring about the best in everyone he encountered. Indefatigable, mischievous, generous, brilliant, soulful, sceptical, idealistic, beloved. A giant.”
And from Hollywood actor, Edward Norton, “What heartbreak to hear this news. Paul Farmer is without a doubt one of the most loving, funny, generous and inspiring people to grace humanity with his soul, in our life times. If you were lucky enough to know him, your life was altered for the better. Dr Paul forever in our hearts.”
In a statement issued on behalf of his family, former President Bill Clinton, talked of a “brilliant, passionate, kind and humble” man, “who saw every day as an opportunity to teach, learn, give and serve” and in whose company “it was impossible to spend any amount of time, and not feel the same.”
Paul Farmer came to world prominence around 2000, when still training, at Harvard University, in his specialism of infectious diseases. He had studied anthropology and medicine, perhaps a sign of his thinking, even then. First listen and understand the people you want to heal.
It was, in his own words, as a “naïve but well meaning” young person, that he went to impoverished Haiti, from his native United States of America (USA). There, he was confronted with the kind of need that would have made most throw up their arms in despair, indeed, many had. He arrived at the height of the HIV/AIDs and tuberculosis epidemic, for the people of Haiti, as it was for most of the less advanced parts of the world.
His reaction was revealing. He would later say, of his arrival in Haiti, that “I was lucky enough to end up in a squatter settlement of peasants, who’d lost their land to a hydro electric dam…so the choices were very stark…” Note the “lucky enough.” For him, not chancing upon those in most need, would have been a stroke of bad luck.
And so, with a few colleagues, the “naïve, but well meaning young person” went about trying to find the best way of meeting what must have seemed like unquenchable need. In some ways, there was nothing new, or unusual in this. Young people, from the privileged West, going to the aid of poor unfortunates.
But something was qualitatively, radically different with this particular young person. First of all, he insisted on the importance of asking the people themselves, what, if they could get it, they thought was most important for them.
Many, including among those he sought to help, were amused, and laughed at him, but they played along, and responded. A hospital would be nice, they said. Somewhere so that if you were in trouble in childbirth, for instance, you could go and get help.
Then a hospital it would be. He went looking for help, and in due course, the people had their hospital. But this would not be just any hospital. What he had built, was Farmer’s idea of what a hospital should be. A place where patients can heal, not just physically, but spiritually, mentally rest.
He had begun his fight for the rights of his patients, not just the right to healthcare, but as he would put it, “the right to eat”, the right to dignity.
According to Celine Gounder, a specialist in infectious diseases, at New York University School of Medicine, and one of innumerable colleagues to be inspired by him, Farmer viewed medicine holistically, through a lens of justice. “What makes Paul’s loss, in this moment, so devastating for most us” she said, “is that he is precisely the kind of leader we need in public health at this moment.”
In the world Farmer was entering, as a young doctor, barely out of training, the orthodoxy within the development community, was that extending access to antiretroviral drugs, to people with HIV/AIDS in poorer nations, was impractical, a near impossibility.
It was authoritatively asserted that the rural poor of less advanced nations, would not be able to properly take the complicated cocktail of drugs in the right rotation, or that they could not keep them safe without proper refrigeration, that they just simply could not cope.
It is an attitude in which Joia Mukherjee, now Associate Professor at Harvard Medical School, had been working in various parts of the poorer world. When she met Farmer, she was as she describes herself then, a “disillusioned” young doctor. “There was all this racist stuff, that Africans couldn’t keep time, wouldn’t know when to take medication…”
Meeting farmer rekindled not only her enthusiasm for her vocation, but her idealism. She mourns a colleague of “fierce intellect, expansive heart, generosity, an enthusiasm and joy for service that was unparalleled.”
Beginning with his patients in Haiti, Farmer steadfastly, upended these prevailing narratives, about the poor. But he did more than that. He insisted that his poorest patients in Haiti, did not only deserve, but can, and must have the same level of care that was available to his privileged patients in America.
It is of course a sentiment to which many people, including the powerful and decision makers, would subscribe, in word at any rate. For most however, it would end there. The conviction that it could actually be done, would be regarded as naïve, unrealistic.
The young Dr Farmer not only lived the ideal he envisaged, but from a small corner of Haiti, he would go on to demonstrate in four continents, that the ideal, not only could be, but actually was the more practical reality.
Before long, the community based healthcare system, he established in Haiti, was surpassing the service America’s poorest were getting. America boasts arguably, the most advanced medical expertise in the world, but it is also the most inequitable.
When he begun to bring that quality of service to the disadvantaged sections of the community, in his home country, he was ribbed that he was raising USA standards of care, to Haitian standards.
There are certain recurring themes in Farmer’s life, standards is one such theme. Joia Mukherjee remembers these exacting standards.
“The standards” she recalls with a knowing smile, “we all had to live with them. Standards of care, standards of dignity…all the hospitals that Paul was involved in building, are beautiful places…There was no first, second or third world, the standards were high for everyone…”
“The idea that some lives matter less, is the root of all that is wrong with the world” he was quoted as saying.
There are now colleagues in places as far afield as Russia, Peru, South America, the USA, and of course, different parts of Africa, who will attest to this high ambition.
These soaring standards can now be witnessed wherever the organisation, Partners in Health (PIH) works.
Founded in 1987 by Farmer, with his colleagues, Jim Yong Kim, Ophelia Dahl, Todd McCormack, and Thomas J White, Bill Clinton says of organisation, Farmer’s “pioneering work with Partners in Health, touched millions of lives, advanced global health equity, and fundamentally changed the way healthcare is delivered…”
If his innovations begun in Haiti, it is in Rwanda that Paul Farmer saw the deepest and most abundant flowering of his ideals.
His work in the country begun in earnest, in 2013. In a recent interview, he was asked, why Rwanda?
“The work in Rwanda” he said, “has been uplifting for PIH, for me, for our partners from Harvard…we made a bet almost ten years ago, that if we could take the model, a system that has hospitals, clinics and community based healthcare, if we could to a place with great need, post conflict setting, maybe even one written off as hopeless, but with a government committed to rolling out basic services, in health and education, to poor people, in rural area, if we could find all that, we would see something miraculous happen, in the course of a decade. And we did.”
“That’s why we went to Rwanda. We went with the Clinton Foundation, and other partners, and worked with the Ministry of Health. I spent the most reward decade of my life, as a doctor, just to see how quickly the reversal of fortune can happen.”
At the ceremony where Farmer was awarded Rwanda’s Igihango medal, President Kagame, reinforced these observations, telling the small, select gathering, that Rwanda’s healthcare infrastructure, had been built around the Doctor Farmer’s innovations.
Turning to the him, with characteristic understatement, the head of state, said to Farmer, that the award was “just a word of gratitude to you, for your work, not only here in Rwanda, but across the world. You have elevated global health to a level where it should be, and you’ve brought part of it with you, to Rwanda. What you’ve done over the years in our country particularly, has been at the centre of Rwanda’s development in that sector…”
Traditionally, Igihango, loosely translated, is a compact between individuals, families or between a nation and an individual, an unbreakable, sacred bond sealed in blood, in which both parties are irrevocably committed to come to each other’s succour, under any given circumstances.
With typical modesty, in what will now be a heart rending, poignant speech to everyone watching it, let alone those who knew him, Farmer declared himself yet to be deserving of the honour, but committed himself to continue to work towards being so.
Composing himself to contain his emotion, he gave a gracious heartfelt glimpse of what Rwanda meant to him.
“I have been lucky enough to be a friend of Rwanda, for decades, and lucky enough to be a Rwandan citizen for over one, and I have also considered this country to be my teacher, and my friend. And if a nation can incarnate in people, I am sitting in a roomful of people who have made this nation a lesson for the world.”
“I am also sitting with my closest friends and family, who’ve treated me like a family member for all these years, who’ve taken me into their home, who’ve taught me, sheltered me, nursed me, amused me, made me laugh…”
“This place has been for me a beacon, and the hard efforts of people who have built this nation, in the last twenty-five years, from my colleagues, who were here in 1994, when they were still teenagers…to my colleagues who have worked with us in building medical services, not just in Rubavu, Kirehe and Burera districts, but elsewhere in this nation, to my teachers…especially my teachers, Paul and Jeanette Kagame…I can only express my gratitude, and hope that I can be of service, over the next twenty years, and beyond, if I am spared…”
We now know that he carried a heart condition, which he will inevitably have known how to manage well, but not even he could do anything, if as it seems to have done, came upon him in his sleep.
In the time that he was spared, he did more, not only in Rwanda, but around the world, than most people would manage in several lifetimes.
Reading one of his short biographies, leaves one wondering where he would magic the extra hours, beyond the twenty-four allotted to other mortals.
“Paul Farmer is UN’s Deputy Special Envoy for Haiti, and Chair of Global Health and Social Medicine at Harvard. He is also Professor of anthropology at Harvard Medical School, chief of Social Medicine and Inequalities at Boston Brigham and Women’s hospital, and founding director of Partners in Health…”
On and on it goes, not to mention authoring scores of books, papers for almost every major specialist medical journey, from the Lancet, to the Bulletin of the World Health Organisation, and all the while ministering to patients too. The title of his biography, by Tracy Kidder, Mountains beyond Mountains, could seem overblown for most people, but is perfectly apt, for Farmer.
In Haiti, where a sizable section of the population hold belief in the occult, and ailments are often blamed on sorcery, many were convinced that their “Dokte Paul” or simply “Polo” had God given healing powers. Some were convinced that he worked “with both hands” meaning a doctor who practised both orthodox medicine, and understands how to cure the supposedly bewitched.
In Rwanda, he was variously, “Muganga wacu” or “Muganga mwiza” our doctor, or the good doctor. It is a country he grew to love, and which in turn took him to its heart. It is also a country which fully grasped his innovations in public health.
For Joia Mukherjee, there is comfort to be drawn from the community of people in public health around the world, who will continue to be inspired by Paul Farmer.
“I feel grateful that we know what to do to honour his legacy. A community of people in public health around the world, concerned with global health, social medicine, social justice. He left us a clear road map for equity and justice for everyone, in his writing in his speeches…to love one another, to take care for the sick, to fight for higher, fair standards. It’s a radical notion, but he’s broken it down for us.”
More than probably anywhere else in the world, it is in Rwanda, that Farmer’s innovations were fully embraced, applied and implemented.
In his own words, looking at the numbers, “declines in mortality, especially amongst children, women in child birth, declines in mortality among those already with Malaria, HIV/Aids, Tuberculosis, these are the steepest declines ever recorded in human history.”
As President Kagame was keen to point out, Paul Farmer was at the centre of these achievements.
In Rwanda’s northern province district of Burera, is Butaro cancer centre, or Butaro Cancer Centre of Excellence. It is the only such centre to be found in any rural area of Africa. A statement of intent by both PIH, and the government of Rwanda.
Speaking for his family, as they mourned Dr Farmer, former President Baraka Obama, said of him, “his life was an example of how one man with vision and heart, can change the world for the better.”
And that too is Paul Farmer’s legacy. He showed how, armed with nothing more than his God given mind, charm, drive and determination, but above all moral courage, founded on love, care and affection for his fellow human beings, a young person, a young man, in this instance, still learning his calling, can hold on to his ideals, and tilt the world towards them. It is an extraordinary legacy.
Nothing will lessen the intensity of the sadness of his sudden, untimely, death, especially for those closest to him, but it may perhaps be comforting that he died in a place he loved, among people who could not have loved him more, doing what he loved, his lifetime’s work bearing fruit, and with a certainty of even greater achievements ahead.
Asked by a colleague what kept him going, where so many became disillusioned with what was happening in global health, he replied, “doing hard things with friends.”
He died happy, a man at ease with himself, and the world around him, a man complete, still straining at the leash to do even more with a life lived in the service of others, and the highest goals.