Paul Farmer with mom and baby. Photograph Source: User:Cjmadson – CC BY 3.0
Only half-jokingly, I often say that the reason that I am involved in medical education is to be able to say to students, “You don’t know who Paul Farmer is? Well, he’s just the greatest international rock star of bringing health care to the poor.”
In his public pronouncements about how he thinks about the October 7, 2023 Al Aqsa Flood operation – Norman Finkelstein says that with Noam Chomsky out of commission, he is forced to reason morally and ethically on his own. Indeed, I feel much the same way about Chomsky myself. I also feel that way about Paul Farmer. In my being-in-the-world as a health practitioner, Farmer has served as a moral compass. Since his passing in February 2022, I feel that I am forced to reason morally and ethically on my own. I do, however, believe that we can keep our friends with us by continuing to engage with them.
When I was a resident at Cook County Hospital in Chicago in the late 1980s, my patients with HIV/AIDS would inevitably die, mostly of opportunistic infections. With the advent of highly active antiretroviral therapy, announced in 1996, HIV/AIDS became a treatable condition. The antiretrovirals don’t cure you of the virus, but as long as you take the medications every day, the virus is suppressed. The problem was that most of the people with HIV/AIDS lived in developing countries, and the new therapy (with proprietary medications) cost on the order of $13,000 per year. The administrator of the U.S. Agency for International Development (USAID), in Congressional testimony in 2001, specifically opposed antiretroviral treatment for Africans because, he claimed, “They do not use western means for telling time. They use the sun. These drugs have to be administered during a certain sequence of time during the day – and when you say take it at 10:00, people will say, what do you mean by 10:00?”
Farmer, having built a hospital in Central Haiti, managed to beg, borrow, and steal the antivirals from Harvard hospitals. He hired community health workers (accompagnateurs) to deliver the medications on a daily basis (directly-observed therapy). At the 2002 International AIDS Conference, he presented the successful results of the Haiti Partners in Health program. At the time, only Brazil had a national antiretroviral program.
Farmer was also invited to the White House by Anthony Fauci to present the Partners in Health findings. Subsequently, at his January 2003 State of the Union address, George W. Bush announced the Presidential Emergency Program for AIDS Relief (PEPFAR) to provide antiretroviral therapy for people living with HIV/AIDS in low-income countries. Of note, during this address Bush also essentially announced the invasion of Iraq, which would start in March 2003.
While the new Trump administration has halted a substantial proportion of foreign aid assistance, much of it funneled through the USAID – apparently PEPFAR falls under the humanitarian waiver announced by Secretary of State Rubio in January. Some PEPFAR programs such as pre-exposure prophylaxis (PrEP) will be restricted, however. Moreover, the funding for the health care workforce that delivers the antiretrovirals has been cut. We must keep in mind that interruptions of even a few days of antiretroviral therapy can have dire consequences. (You don’t die of opportunistic infections right away, but the remaining HIV virus in the body becomes resistant, so the first-line antiretrovirals don’t work any more.)
Undoubtedly Paul would have been saddened by the current situation. After all, he believed in health as a human right, and that all humans must be included “under the rubric ‘human.’” Probably mustering all his charisma, he managed to convince the government bureaucrats of this (not so radical) notion.
In late 2009 I was in Boston for a medical meeting, and I met Paul over dinner. He happened to be staying at a hotel north of Harvard Square. I arrived and told the front desk person that I was there to meet Dr. Farmer. He came downstairs after a while and apologetically said, “Sorry, I was on the phone with Bill.” At the time, Paul was serving in a volunteer role as the United Nations Deputy Special Envoy to Haiti, under Bill Clinton.
Over dinner, Paul told me that he had been reading about the FDR administration. He was inspired by the ideal of public, meaning government, service. By this time, Paul had moved his family and his work to Rwanda. Rather than focusing on a charity, as he had initially done in Haiti – Farmer was working with the post-genocide government to improve public services for health.
He told me of how the Obama administration, specifically the Hillary Clinton State Department, had wanted to nominate him to become the administrator of USAID. In preparation for his Senate confirmation hearings, he had brought two bags of his books and papers to the State Department – so that staffers could comb through them for anything that might be construed as disqualifying by unfriendly Senators. For example, in his early books about Haiti, he had recounted how, in response to cases of African swine fever, in 1981-83 the Haitian Kreyol pigs were exterminated. With USAID funds, they were replaced with Iowa porkers, which were unsuited to the Haitian environs and quickly died off – leading to economic disaster for the Haitian peasantry. (See “When the Clintons Did Haiti,” on the Clinton administration’s USAID population control program in Haiti during the 1990s.) The geographically broad and historically deep context, as Farmer was wont to say, was to view Haiti as a Latin American country, in the colonial and neo-colonial orbit of the U.S. The Papa Doc and Baby Doc Duvalier regimes were continually backed by the U.S.
Seemingly changing the subject, Paul asked if I had read the recent Jane Mayer piece in The New Yorker (The Predator War, 19 Oct 2009) about the White House CIA drone program. No, I hadn’t. By the time of that article in late 2009, Obama had launched as many drone strikes on Pakistan as had the George W. Bush administration during its last three years. It came out later that this was a regularly scheduled weekly Tuesday morning appointment for Obama, to choose who would be extrajudicially killed by drone. Paul asked, “Did you know that the administrator of the USAID is on the National Security Council?” No, I hadn’t known that.
“I just couldn’t be a part of that,” said Paul.
Sure, Paul Farmer would have been an unparalleled public servant. After all, one of his mottoes was “to move resources from where they are to where they are not.” Under him, there probably would have been fewer incompetent screw-ups like the pig extermination episode. But he had no illusions about the role of the U.S. in the world. He asked about one international relations journal, “Would that be the journal for war criminals, or is that the one for budding war criminals?” In the end, he just couldn’t be a part of that.
Yeah, Paul was buddies with Bill. But being invited to be buddies with Hillary and Barack, too? He could tell that his acquiescence was being sought for some nefarious ends. He could tell that he was being set up as a patsy for the deep state.
