Tracing Paul Farmer’s Influence
This year the College of Arts and Sciences was honored to feature as its commencement speaker Dr. Paul Farmer, internationally renowned global health advocate, medical anthropologist, cofounder of Partners In Health, and chair of the Department of Global Health and Social Medicine at Harvard Medical School. He also serves as U.N. Special Adviser to the Secretary-General on Community-based Medicine and Lessons from Haiti. In this essay, Professor David Vine, who teaches in the College’s Department of Anthropology, describes Farmer’s lasting influence and inspiration to anthropologists.
Although Paul Farmer’s many accomplishments as a doctor sometimes obscure his training as a medical anthropologist, he is easily the most publically influential anthropologist since Margaret Mead and her mentor, the “founding father” of U.S. anthropology, Franz Boas. For more than two decades, Farmer has inspired a generation of anthropologists, from undergraduate and graduate students to faculty members (like me), among the thousands of others whose lives he has touched.
At the core of Farmer’s anthropology, as well as his skills as a doctor and public health worker, is his commitment to seeing the world from the perspective of the planet’s poorest. Unlike many doctors (and anthropologists for that matter), Farmer has lived for decades with his patients, first in Haiti and later in communities from Rwanda to impoverished neighborhoods in Boston. “It took me a relatively short time in Haiti,” Farmer writes of the beginnings of his career in his 2003 book Pathologies of Power, “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.”
Out of this experience witnessing poverty and the sickness it inflicts, Farmer’s work is unflinchingly committed to social justice, global equity, and the idea that health care is a human right, beginning with what he calls “the most basic right . . . to survive.” Like his medicine, Farmer’s anthropology is thus an anthropology in service to the poor. Importantly, this does not mean an anthropology of the poor. Farmer is well aware that “writing of the plight of the oppressed is not a particularly effective way of assisting them.” After all, anything one might say is likely to be used against them. Instead, Farmer is interested in studying and exposing the “processes and forces that conspire” to constrain the agency of the poor and that cause poverty, disease, and suffering.
This interest in the root causes of poverty and the diseases Farmer treats as a physician has led to one of Farmer’s greatest intellectual contributions—his analysis of “structural violence.” Drawing on the work of Norwegian sociologist Johan Galtung, Farmer calls attention to powerful forms of everyday violence, like poverty, hunger, and poor health, that can be just as deadly as the violence of bullets and war but that tends to be caused by social forces, political and economic institutions, and the decisions of policymakers. In the paradigmatic example Farmer uses to explain structural violence, he shows how the root causes of a Haitian contracting HIV/AIDS are to be found not in personal irresponsibility but in the displacement of a village by a dam planned and funded by powerful actors in Washington, D.C.; by the impoverishment the dam created; and by the long-term impoverishment of Haiti through centuries of subjugation at the hands of the United States and European powers dating to the days of slavery.
Despite this structural perspective, Farmer is by no means uninterested in the experience of individuals. To the contrary, his work as both an anthropologist and a physician revolves around the lives of individuals suffering amid powerful structural forces. Farmer’s anthropology is a holistic science involving many of the social and natural sciences: He combines an empathetic understanding of people’s lived experience and how people make meaning in their lives with a political, economic, and historical analysis of the large-scale forces that shape individual lives. Coupled with an appreciation for the biological vectors of disease causation, Farmer’s is a bio-sociocultural-political-economic-historical anthropology.
As important as these unusual intellectual contributions have been, Farmer’s influence stems equally from his tireless commitment to creating positive social change and to using his anthropological and medical skills to help improve the lives of the poor. (When told he should spend more time with his wife and child in Paris, Farmer responded, “But I don’t have any patients there.”) Critically, for all the talk of “Saint Paul,” Farmer’s vision is not one of an outside savior delivering the poor from destitution. Instead, Farmer and Partners In Health, the organization he helped found with Ophelia Dahl (now its executive director) and Jim Yong Kim (now president of the World Bank), emphasize working in solidarity with those they serve; training Haitians and others to become doctors, nurses, and community health care workers; and building sustainable health care infrastructures designed to be part of public health care systems.
In his 2003 biography of Farmer, Mountains Beyond Mountains, Tracy Kidder described some of the profound impact Partners in Health and its Haitian counterpart organization Zanmi Lasante have had in what is the poorest country in the Western Hemisphere:
Zanmi Lasante had built schools and houses and communal sanitation and water systems throughout its catchment area [in central Haiti]. It had vaccinated all the children, and had greatly reduced both local malnutrition and infant mortality. It had launched programs for women’s literacy and for the prevention of AIDS, and in its catchment area had reduced the rate of HIV transmission from mothers to babies to 4 percent—about half the current rate in the United States. A few years back, when Haiti had suffered an outbreak of typhoid resistant to the drugs usually used to treat it, Zanmi Lasante had imported an effective but expensive antibiotic, cleaned up the local water supplies, and stopped the outbreak throughout the central plateau. In Haiti, tuberculosis still killed more adults than any other disease, but no one in Zanmi Lasante’s catchment area had died from it since 1988.
A decade later, Partners in Health (PIH) has accomplished far more. PIH now serves some 2.4 million people in 12 countries, in settings that include post-genocide Rwanda, Peruvian slums, and Russia’s prisons. In devastated post-earthquake Haiti, PIH recently inaugurated a 300-bed, state-of-the-art, solar-powered university teaching hospital that represents the country’s largest post-earthquake reconstruction project.
There is perhaps no better symbol of PIH’s and Farmer’s commitment to providing the highest quality health care to the poorest of the poor than a world-class university hospital in a part of Haiti that doesn’t even have a university. In building the hospital and throughout their work, PIH and Farmer reject conventional public health wisdom about what’s “possible” in the provision of health care in impoverished settings. They reject arguments that treatments available in wealthy countries like the United States aren’t “cost effective” in settings like Haiti. Guided by the radical idea that all human lives are equal, that PIH should provide the same quality of care to the poor that the wealthy want for their own family members, that health care is a human right, PIH and Farmer demand nothing less than a “preferential option for the poor.”
“That goal is nothing less than the refashioning of our world into one in which no one starves, drinks impure water, lives in fear of the powerful and violent, or dies ill and unattended,” Farmer says in an National Public Radio “This I Believe” essay.
“Of course such a world is a utopia,” Farmer continues, “and most of us know that we live in a dystopia. But all of us carry somewhere within us the belief that moving away from dystopia moves us towards something better and more humane. I still believe this.”
Farmer and all those he has worked with at PIH have made many of us believe. Like his anthropological ancestors Mead and Boas, Farmer has inspired anthropologists and others like me in both our heads and our hearts. He has created an anthropology in service to the poor, the sick, and those on the underside of the globe’s inequities. And in the process, he has forced anthropologists to confront a question posed by Mexican anthropologist Rosalva Hernández Castillo that we should ask of all our disciplinary affiliations: In a world of tremendous inequality, in a world that is both “satisfying to us” and “utterly devastating to them,” in a world of such suffering, “¿Antropología para que?”
Anthropology for what?