An Interview With Dr. Paul Farmer

In this Q&A, Dr. Paul Farmer gives insights on student activism in global health, and methods for combatting health inequality. Dr. Farmer is a physician and anthropologist, co-founder and chief strategist of Partners In Health (PIH), and Kolokotrones University Professor and chair of the Department of Global Health and Social Medicine at Harvard Medical School. The author of several books including In the Company of the Poor: Conversations with Dr. Paul Farmer and Fr. Gustavo Gutierrez,  Reimaging Global Health: An Introduction, and To Repair the World: Paul Farmer Speaks to the Next Generation, Dr. Farmer’s writings address social justice in medicine and health inequalities worldwide.

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1.  How do you think university students, premed and otherwise, can best fight structural injustices that lead to inequity in healthcare? Are there everyday actions we can take?

We hear this question often, and it’s a marker, for me, of students’ desire to be useful. This desire should always be celebrated. The social contract that students make by attending a university is to attend it. And that means your community and proximity is, for example, in St. Louis, and even if your interests lie in settings like rural Haiti, Rwanda, a prison in Siberia, a forest village in Liberia, you have this challenge that all of us face: you can only be in one place at a time. The good news is that there’s so much to do in the area at a place like Washington University. I don’t think I’ve ever been to an American city that doesn’t face the kind of structural injustice and unfairness that lie at the heart of many health problems. So one of the first things I’d encourage students to do is to raise their eyes and look around, and to find neighbors who are dedicating much of their time to addressing such problems. Students are not able to address most of their time to anything other than their studies, so finding good partners to learn from and work with, no matter how many hours a week you might have, is a great way of becoming an activist. Another way, of course, is to join student organizations. PIH has for decades benefited financially and morally and spiritually from student groups. Third, the great thing about being in a great college or university like this one, is that you have faculty and peers and the ability to dedicate your attention to the things you learned in a classroom, or in a library, or in a study group. It’s no exaggeration to say that for me, in any case, I got on the path I am on now while a full-time student at Duke. PIH was in many senses started by students and is constantly infused by youthful enthusiasm and new ideas because we teach, and because of groups like GlobeMed Engage.

2. My peers interested in healthcare often express that they find it difficult to mentally and practically align local efforts with global goals. What advice do you have in terms of seeking this balance?

This is a good question and one that all of us have to face for the reason mentioned above—you can only be in one place at a time. Yet problems are never only local. Certainly that’s the case with epidemic disease, which is my area of interest, but also with overwhelming and difficult to seize problems like fair trade, violence and war, and the kind of trafficking that has marked the part of West Africa (for centuries) in which PIH is now heavily involved. Even “new epidemics” of, say, obesity, or diabetes are embodied locally, in people and families right around us, but are the result of what you’ve called “global forces” well beyond our reach. As clinicians or community activists or students, we’re stranded happily in islands of privileged, like the one in which we stand today. One of the ways to address this challenge is to link humble service—what a friend of mine calls the “Ministry of Showing Up”—to the process of discernment about the nature of these truly global problems, which can then lead to informed activism of a very different sort. These are complementary actions, just like local and global ones.

3. You describe the PIH mission as one “based on solidarity, rather than charity alone.” Could you describe the relationship and difference between the two, and how they fit together at the community level?

Charity is not to be dismissed. It’s one of the cardinal virtues, and rarely completely out of place in addressing acute need. In my line of work, one is always reminded that there are real imbalances—between the well and the sick, the young and the old, the rich and the poor—and sometimes sentiments of charity, mercy, compassion are exactly what’s required for any humane response. That said, one goal is to attack social inequalities like racism or gender inequality, and this is a long-term and greater aspiration that will not be met by unstable and short-term acts of charity. Solidarity should be linked to pragmatic efforts to make the world a less unfair place. One of the biggest worries I have is the growing economic inequality within and across country. Charity is not going to reverse this.

4. In your opinion, what is the biggest challenge facing the future of “social medicine” today?

As an analytic endeavor, the biggest problem is an increasing inability to integrate vast amounts of new and sometimes recovered knowledge from highly specialized fields, but I’m guessing you are thinking of “social medicine” as an analytically sound means of intervening to address human suffering caused by disease? The biggest problem I see is a failure of imagination when the problems at hand affect primarily the poor. I’ve seen this in every place we’ve worked, from Rwanda to Russia to Boston, and this failure reveals itself, often, by lowering standards of care for the poor. This failure, of course, is fatally linked to the idea that some lives matter less than others. Ninety percent of the problems social medicine should address would be lessened by rejecting this notion and insisting on high aspirations for those who haven’t enjoyed the fruits of medicine and public health.

5. From my experience at this university, it often seems students interested in careers in medicine and public health themselves come from a place of socioeconomic privilege. How would you encourage such a group to think about responsibility distribution when it comes to providing a “preferential option for the poor”?

Lucky them. Lucky us. If we’re at a university we are, by definition, among the fortunate few and I think one of the first steps is to acknowledge and be grateful for such privilege. As my friend, Jim Yong Kim, used to say, “there’s not a long line of people waiting to serve the poor.” Of course, real solidarity requires that we respect people who are poor or otherwise marginalized as the agents of their own destinies, but I can’t think of any reason to disparage activism, service, and gratitude among the privileged, in turning that towards a preferential of the poor.

6. Lastly, can you point to any formative experiences you had in college that helped shape your worldview and/or career path?

These will sound pretty pedestrian, but since they’re true, I’m just going to list them: taking a class in medical anthropology at Duke, being allowed to learn from generous young doctors in the emergency room, writing for student publications, and being part of student activist groups on campus. Of course, I had incredibly generous teachers and I tried to imitate them to this.