Dr. Paul Farmer

An Example of "Charismatic Authority"

One of the most powerful and inspiring books I have ever read is “Mountains After Mountains” by Tracy Kidder. It is a profile of Dr. Paul Farmer who accomplished what many thought was impossible. He saved thousands of lives with little resources. He did it by respecting local cultures. He did it by creative persistence in the face of enormous obstacles. Paul Farmer died this year - hard at work at only 62. I cried when I read the news. Read the book. You may cry too. https://www.tracykidder.com/mountains-beyond-mountains.html

What follows is a recap from an opinion columnist at the NYTimes. It’s also a giving suggestion. After the article is a no paywall link to the original article published today. Consider reading the book. Consider giving to PIH. Consider giving the book which was first published 20 years ago. It is a timeless lesson in how someone can defy convention and make an enormous difference.



By Zeynep Tufekci

Opinion Columnist

Shortly after Paul Farmer helped get Partners in Health off the ground in 1987, international global health groups were debating whether it was even possible to treat poor patients with multidrug-resistant tuberculosis, as its treatments were expensive and required patients to stick to complicated regimens. Indeed, even ordinary tuberculosis for which cheaper drugs and proven regimens existed kept killing poor people around the world.

Farmer, and the band of can-do mavericks who had assembled around P.I.H., had no patience for such excuses — or any excuses for denying care to poor people.

Their programs, based on providing high-quality care regardless of patients’ ability to pay and empowering them in their own treatment, were so successful that they upended global public health.

In his biography of Farmer, “Mountains Beyond Mountains,” from 2003, Tracy Kidder noted that even as tuberculosis killed more adults than any other disease in Haiti, not a single person had died of it since 1988 in the P.I.H. hospital that served a desperately poor rural area with a population of about 100,000 people. Protocols the group developed in Peru for successfully treating multidrug-resistant tuberculosis were adopted globally.

After learning about Farmer and P.I.H. from Kidder’s book, I’ve been donating to the organization ever since.

This year is particularly poignant, though. Farmer died in February.

According to Kidder, P.I.H. reduced newborn H.I.V. transmission from mothers to babies in the rural Haitian community it served to 4 percent, which he also noted was less than the rate in the United States at the time. Their clinic stopped outbreaks of drug-resistant typhoid with effective antibiotics and by cleaning up water supplies. It drastically reduced infant mortality. They achieved this despite a meager budget and with many patients traveling for hours, sometimes on foot or by donkey.

How? Farmer had a very straightforward philosophy: All sick people deserve high-quality treatment. Illness and poverty are intertwined. The proper response is to provide resources while working with people to empower them — thus Partners in Health.

The secret? Treat the whole person. With respect.

Poor patients needed more than drugs to get well, so Partners in Health provided them with food, too. They provided school fees to children. They installed systems to purify the water that caused so much disease. And they always trained and hired local staff, who would follow up with patients to identify and help remove obstacles to their treatment.

Farmer, a Harvard-educated physician, was also trained as a medical anthropologist. Kidder wrote that Farmer learned from local staff that more than three-quarters of Voodoo ceremonies were attempts to drive away illness. He saw little reason to argue with people about beliefs and faith; instead, he always focused on providing high-quality health care. Voodoo priests that he treated ended up as conveyor belts to the clinic, bringing their own ill parishioners to be treated. Farmer approached people with humility and respect, which they reciprocated.

Farmer’s own lapsed Catholicism was rejuvenated by his encounters with liberation theology, with its sharp criticism of inequality and injustice. He didn’t see theology as an obstacle to his mission. He’d say he had “faith” but also add: “I also have faith in penicillin, rifampin, isoniazid and the good absorption of the fluoroquinolones, in bench science, clinical trials, scientific progress, that H.I.V. is the cause of every case of AIDS, that the rich oppress the poor, that wealth is flowing in the wrong direction, that this will cause more epidemics and kill millions.”

Farmer was only 62 when he died, while training staff in a Rwandan hospital he helped establish. He had lived nonstop, treating patients around the world as well as fund-raising, cajoling, pleading and teaching.

Sociologists recognize a form of power called “charismatic authority” — Max Weber called it “the authority of the extraordinary and personal gift of grace.” Farmer certainly represented that. He inspired a generation of doctors, nurses, public health workers and advocates and ordinary people. He used the respect and awe he garnered to lobby global leaders and to help lead the charge to change how public health operates.

But what happens to a movement when its charismatic leader dies? In this case, the best option is what sociologists call “routinization of charisma” — things keep working because they become entrenched and institutionalized, not just because someone extraordinary wields enormous personal influence.

Since the early days, P.I.H. had already grown larger and more institutionalized, attracting millions in donations from individuals as well as foundations. They’ve expanded from Haiti and Peru to places like Rwanda, Sierra Leone, Lesotho and Navajo Nation. But they’re still small compared to the need. And their kind of work is even more crucial now, since the pandemic didn’t just cause suffering through Covid-19 — much basic health care has been interrupted around the world. As it always goes, the poorest, globally, will suffer the most from these disruptions, which will require an extensive effort to ameliorate.

Paul Farmer’s answer to “how does one scale this up” seemed to be simple: follow the basic principles of dignity, training and empowering local people and giving them resources. Money always matters.

Too often, the burning, basic question of lack of resources gets buried under debates about the effectiveness of various approaches and worries about being pragmatic or sensible. But as Farmer pointed out, many who advocate for “sensible” policies that ended up doing too little for the poor and sick “would never accept such a death sentence themselves” or their children.

Would I prefer a global tax policy that redistributed wealth to alleviate poverty and illness, rather than relying on N.G.O.s like P.I.H.? Yes. But we can’t just wait for an ideal resolution when desperate families need a clinic where they will be treated for free, perhaps provided food and school fees.

This year, I’m writing my check for P.I.H. not just because of their good work in some of the toughest places around the world but also with the hope that Paul Farmer’s legacy of providing treatment, respect and empowerment to all patients can endure and even thrive. When one donates online to P.I.H., there’s a box that asks if it’s in memory of someone. I’m going to write Paul Farmer there, and hope they get enough extra donations, maybe even for another clinic somewhere, because saving lives now is what matters.

This article is part of Times Opinion’s Giving Guide 2022. The author has no direct connection to the organizations mentioned. If you are interested in any organization mentioned in Times Opinion’s Giving Guide 2022, please go directly to its website. Neither the authors nor The Times will be able to address queries about the groups or facilitate donations.

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Zeynep Tufekci (@zeynep) is a professor at Columbia University, the author of “Twitter and Tear Gas: The Power and Fragility of Networked Protest” and a New York Times Opinion columnist.


Below is a gifted link (skip the pay wall) to the original article:

Honor the Vision of Dr. Paul Farmer