The award-winning physician Paul Farmer, MD, PhD—who passed away suddenly in February 2022—sought to address the healthcare needs of patients in low-resource settings via community-based treatments.
Farmer was chair of the Department of Global Health and Social Medicine at Harvard Medical School and cofounder of Partners in Health—a global health organization that centers on social justice work—and he authored many pieces on the medical consequences borne by social inequalities.
Doctors may integrate Farmer’s lessons into their practice by following the “Five S’s” in their approach to care (staff, stuff, space, systems, and social support), in addition to “breaking bread” with those in need of healthcare to better support them.
The late Paul Farmer, MD, PhD, changed the lives of countless doctors with his ideas, writings, and healthcare practices. The prestigious infectious disease specialist worked with low-resource communities around the world and co-authored several books and articles on the link between social inequalities and inadequate health systems.
Among his many academic and professional accomplishments, Farmer facilitated a holistic approach to healthcare that is bound to inspire his peers long after his sudden death on February 21, 2022.
Dedication to poor communities
Farmer was a pioneer of community-based treatments, and he championed high quality healthcare in low-resource areas. A Partners in Health (PIH) article outlines his life’s work and writing in this realm.
One of the manifestations of his efforts to address poverty in medicine is noted in the book he wrote with Fr. Gustavo Gutiérrez, called In the Company of the Poor: Conversations with Dr. Paul Farmer and Fr. Gustavo Gutiérrez.
Farmer explained that PIH’s goals include the application of modern medical science to those most affected by poverty and the mitigation of despair among marginalized populations.
One example he mentioned was the 2010 cholera outbreak in Haiti. Even when the cholera vaccine proved safe and effective after the disease ravaged other parts of Latin America, Farmer noted that relief agencies still struggled with the decision to vaccinate Haitians against their most deadly epidemic to date.
The harmful effects of the disease and the inaction to protect the poor on behalf of those fighting it, Farmer wrote, is partly why cholera was then seen as a disease exclusive to those living with poverty.
Thus, PIH’s integration of the “preferential option for the poor'' cuts to the heart of inadequacies in health systems overall. Solidarity was at the center of Farmer’s work—he stressed the importance of providing high-quality care to those who have the least access to it.Related: Have we removed racial disparity from lung cancer screening?
On COVID-19 in US prisons
A more recent article co-authored by Farmer and published by The New England Journal of Medicine looked at the reasons why the combination of vaccination and decarceration is central to the manageability of COVID-19 in US prisons.
Prisons in the United States are home to almost 25% of the world’s incarcerated individuals. The constant shuffling of people to and from prison undoubtedly contributed to heightened transmission rates of COVID-19 among those incarcerated and those in surrounding communities.
When the aforementioned piece was published in April 2021, more than 620,000 COVID-19 cases had been reported in US prisons alone. Farmer and his co-authors felt that prisons act as “epidemiologic pumps”, which only elevate case numbers and perpetuate racial discrepancies in the effects of COVID-19 in the US.
"We believe that [vaccination] must be coupled with large-scale decarceration to increase the real-world effectiveness of vaccination, disrupt wide-ranging viral transmission chains, and turn off the epidemiologic pump that puts the health of all at risk from mass incarceration."
— Barsky BA, et al.
While widespread vaccination of those who live and work in prisons could mitigate harm, efforts to decarcerate are sure to bear more fruit in the long term. Decarceration includes the release of inmates who do not threaten public safety of others, termination of pretrial detention for those who lack financial resources to post bail, and greater use of home-confinement practices.
The success of decarceration is credited in part for a 56% decrease in transmission rates in a large urban prison immediately following the release of 9% of inmates.
Farmer, along with his co-authors, described why decarceration must be considered in attempts to mitigate widespread transmission of COVID-19.
“Vaccination of incarcerated people is important for changing this dynamic, but it is not enough,” the authors wrote. “We believe that it must be coupled with large-scale decarceration to increase the real-world effectiveness of vaccination, disrupt wide-ranging viral transmission chains, and turn off the epidemiologic pump that puts the health of all at risk from mass incarceration.”Related: Prevalent ethical dilemmas in practice today—as told by doctors
Farmer’s lasting effects
Farmer’s notable philosophies and healthcare practices have influenced many in his field.
Junaid Nabi, MD, a senior researcher in healthcare strategy at Harvard Business School who also serves on the Working Group on Regulatory Considerations for Digital Health and Innovation at the World Health Organization, wrote about Farmer’s impact on him in a StatNews article.
Nabi, who felt overwhelmed with the number of barriers doctors face in delivering care to the world’s most marginalized patients, felt fortunate to encounter Farmer’s work. He emphasized the importance of Farmer’s philosophy regarding treatment: All people deserve high-quality care. Farmer also believed that instead of focusing solely on the disease, HCPs must address the systems surrounding a patient.
Farmer taught Nabi the Five S’s: Staff, stuff, space, systems, and social support. Physicians can use these to focus on vulnerable patients and contextualize their illnesses in the quest for better global healthcare.
In addition to those guides, Farmer taught about “accompaniment.”
According to Nabi, Farmer prioritized total presence with his disadvantaged patients and people in need.
To accompany someone is to “break bread” with them, to listen intently, and to work with them to truly meet a community’s healthcare needs.
Following in Farmer’s footsteps, Nabi called to attention the lack of global COVID-19 vaccine equity. He wrote about the injustice of over 1 billion Africans who are waiting to receive their first dose while more financially privileged nations debate whether to introduce a fourth.
In response to this, Nabi echoed Farmer’s sentiments, which called on global leaders to lead with compassion and accompaniment to provide quality healthcare to those who need it most.
What this means for you
Dr. Paul Farmer’s work revolutionized the lens through which so many doctors understand healthcare. Centering on the systems that serve—or struggle to serve—disadvantaged patients, instead of focusing on an isolated disease, is the crux of what may be Farmer’s biggest lesson.
He believed that a holistic approach to healthcare, which includes a fierce dedication to investigating the social inequalities that shape health systems, is the most effective way to permanently redesign global healthcare for the better. Doctors who want to carry on Farmer’s legacy can do so by using the tool of the Five S’s, practicing accompaniment, and addressing the needs of the most marginalized individuals around the world.
Barsky BA, Reinhart E, Farmer P, Keshavjee S. Vaccination plus decarceration — stopping Covid-19 in jails and prisons. N Engl J Med. 2021;384(17):1583-1585.
Nabi J. What I learned from Paul Farmer: Treat the systems around the patient, not just the disease. StatNews. February 23, 2022.
Partners in Health. Remembering Dr. Paul Farmer. February 21, 2022.
Griffin M, Block JW, eds. In the Company of the Poor: Conversations with Dr. Paul Farmer and Fr. Gustavo Gutierrez. Maryknoll, NY: Orbis Books; 2013.