Medical anthropologist and physician Paul Farmer has dedicated his life to improving health care for the world’s poorest people. He is a founding director of Partners In Health (PIH), an international nonprofit organization that since 1987 has provided direct health care services and undertaken research and advocacy activities on behalf of those who are sick and living in poverty.

Professor Farmer is the Chair of the Department of Global Health and Social Medicine at Harvard Medical School; he is also Chief of the Division of Global Health Equity at Brigham and Women’s Hospital, Boston.

KURIOUS sat down with Professor Farmer shortly after he gave the commencement address at Koç University’s 26th and 27th Graduation Ceremony, to discuss his views on public health, COVID-19 pandemic, equity, education, and how to solve the world’s health problems.


My first question is: Your achievements as a medical anthropologist and physician have made you a folk hero to many people, myself included. It is impossible not to be impressed by your extraordinary efforts. How did this challenging adventure begin?

You know how humans are, they always look to their childhood. It’s a pretty good way to start. Certainly, I’m lucky to come from a family where curiosity was encouraged. But my career in medical anthropology began in a classroom, just like there are at Koç University. I had never really heard of medical anthropology until I saw it advertised in a course catalog at Duke University, where I was an undergrad. And I just loved the course. I had been a biochemistry major, and I loved it so much that I changed my major, really at the end of my college. You know how it is in the United States: You have four years of college and then graduate school. And then, as if that were not enough, I was lucky enough to go to Haiti right after graduating. And that really cemented my idea, out of someone else’s ideas, of how could you be a physician, or a better physician, if you also learned about the social world. And that is really the topic of my graduation speech as well, all these years later.

With many governments today backing away from universal health care policies, the future seems grim for public health. What will this mean for the future of global health? What can countries do to reverse this trend? What could we change to achieve better world health care?

One of the first things that we have to do when we see that kind of retreat from the commitment to universal health care is to fight back. And I mean as citizens, certainly as people involved in public health or medicine, but as citizenry in general. Because the idea of having health care for all is really about all. It is about all of us. So, that stance, we don’t see it enough in the world. It’s when people are afflicted with serious illness or injury that they start thinking, very often, about universal health care. So, that should be something that is broadly supported by the population. And that, of course, is where government officials come from. I mean, they don’t come from another planet. They’re like us. They live in bodies that are subject to illness and injury. I think this last year, this last 15 – 16 months, have thought us a very tough lesson. And it’s taught us a tough lesson even in places where universal health care is embraced at the government level. And that’s not enough. It’s not enough to have, let’s say, a thin layer of protection for everyone. There’s so much more work to be done, again by the broader citizenry. If you look at American medicine, which is practiced in a way that is very similar to in a university hospital in Türkiye if you look at the trends among American physicians over the last century, you go from really efforts to block universal health care or national health insurance schemes, to grudging acceptance, and then at least in the circles that I move in most, the academic medical circles, you have the widespread embrace of universal health care. So, those trends in the profession, not only medicine but nursing as well, are important, but we have such a long way to go. And I think that’s the lesson of COVID, that we need a safety net. And it’s also the lesson of COVID vaccines. Now we’re living through vaccine apartheid. And it’s getting worse right now. So again, I’m going to keep underlining this point: I think this is everybody’s concern, not just of nurses and doctors.

I’m going to ask, what do you think the COVID-19 pandemic has taught us? What do you think might change in how we approach health services?

There are a lot of lessons beyond the ones I mentioned. I think it’s reminded… Almost on a philosophical or spiritual level, it’s reminded people of the frailty of human life. So many people have lost friends and family. I know I have. And we’ve lost so many patients we think should’ve made it. So we’ve learned some very specific lessons about how to provide better care to people with COVID-19. But those were very hard lessons to learn in the thick of the pandemic. We’ve learned about how… I, of course, know   about the American medical system, and not the Turkish one, but we’ve learned, again, that when we don’t invest in public health, or when we divest from public health, as has happened in the United States over the last few decades, the cost can be very high. How do you explain the uniquely poor performance of the United States in responding to COVID? You don’t explain it by saying, “Well, we didn’t have the right ICUs, we didn’t have enough ICU beds or places.

” Well, we certainly did not have the right ICUs and did not have enough ICU beds. But the real explanation lies in divesting from a safety net. Issues like housing insecurity, issues like food insecurity, like the medical deserts that we see in the middle of the United States, often very literally the middle, in rural areas. All of these have really worsened the toll of COVID. I think we’ll be spending a lot of time reflecting on why we’ve done so poorly. Now, where did we do very well in the United States? Well, that’s in scientific research, including that which yielded entirely new kinds of vaccines. So, and why did that happen? It’s not  because of some unique genius American researchers. It’s because we did invest heavily in biomedical research over the years, as we were divesting from public health. And again, you look at Brazil, which actually had a reputation before COVID of having a system able to respond to new challenges, to develop innovative solutions, and they’ve also done uniquely poorly. So we’re also going to have to look at what did our leaders on the federal and also regional levels, what did they do right, and what did they do wrong. I don’t think anybody is confused about, going back to the examples of the worst performers, the United States, and Brazil, we didn’t have good leadership during the crisis. And that cost plenty, and it’s still costing a lot in Brazil.

Do you believe that COVID-19 vaccines are being shared fairly in the world? What problems do you think this may cause in the future?

Only a fool would argue that they’re being shared fairly. They’re being stintingly shared, tardily shared and unfairly shared. And one of the things we’re going to see going forward, at least in the few months and year I think, I fear, is, there’s going to be more of this divergence where one side does better and one side does worse. One side being vaccinated, or the more heavily vaccinated populations, and the other being those where there’s just no vaccine at all. I work in a lot of places where, really on this side of the equation where there isn’t vaccine. In Haiti, for example, there’s really been no significant vaccination campaign. We’re trying to launch one, and the Biden administration has pledged support with the vaccines. And that will help. But just until early in the morning, I was trying to help two of my closest friends, both very sick with COVID in Haiti. And that’s because we just didn’t… I shouldn’t say “we,” but those who should’ve been ordering these vaccines and making sure they had them on hand, didn’t act quickly enough. It’s going to be a very, very tough year. And one of the things that we could do, I think, is to have vaccine production, let’s say, on the continent of Africa. And I’ve been lucky enough to work with the Rwandan authorities on a scheme, an idea, a plan to launch vaccine production of mRNA vaccines, right there in Rwanda. I think that’s going to succeed. I think it’s going to happen, I think it’s going to be a success. Right now, doing the math, we not only don’t have the vaccines where we need them across the world, and India is a very good example in part because it’s always been or long been a leading vaccine producer. But now, as everybody in the world knows, they’ve been scrambling in the middle of a very terrible surge sweeping through its enormous cities. So they’ve had to limit, or they’ve felt compelled to limit their export of vaccines. And, so who knows what’s going to happen. What if we find out that these new variants are not covered at all well by these vaccines? Will have time to reformulate new mRNA vaccines, or other kinds of vaccines to battle the variants? Are we going to need booster shots? If you have, like I have, received an mRNA vaccine, will that protect you from all of these variants that are surging forth now? I hope so, but there’s reason to believe that we’ll need for many years to come a steady supply of vaccines that reaches all areas that face surges, outbreaks, clusters. And we’re not ready for that yet.

Yes, unfortunately. You have fought infectious diseases such as AIDS, Ebola, multi-drug resistant tuberculosis in many countries. And understand social inequality more than most. What is the greatest danger facing health services in the world today?

I always go for a specific place: What are the greatest dangers facing, let’s say, the health services in Haiti, the United States, Rwanda? And it’s different in every place and it’s different every time. When I first started in Rwanda, 20 years ago almost, it was also a medical desert.

So, you look at Rwanda in 2002. There wasn’t the staff, meaning the nurses, doctors, any specialists. There wasn’t the stuff, the supplies, the vaccine is in that category. There wasn’t a safe space. Some districts in Rwanda had no hospitals at all, and those of course were the places where we were sent. They didn’t have the systems, like infection control, keeping the air free of pathogens like tuberculosis, influenza, and COVID. The systems weren’t in place. But what Rwanda did was steadily augment the amount of funding from the national public treasury that went into both care delivery and public health interventions. So now, 20 years later, they are certainly the standout on the continent. They’re the place that has invested the largest fraction of their public dollars in health. And that’s why you see in Rwanda over those 20 years the steepest declines of human mortality ever documented anywhere at any time. And that’s a pretty shocking thing for people to hear. Rwanda, of all places, after what it went through in 1994, is now a standout in terms of health and health care delivery. And also a site of innovation of how to deliver services. Until COVID hit, there were probably more community health workers in that tiny country than there were in the Eastern United States, with many times the population. Now, of course, in the United States, maybe we do need community health workers like in Rwanda, who can serve as living links between a household, a neighborhood, and a clinic. And after that, between a clinic and a hospital. So that’s another system investment. A human-centered design plan to make health care accessible to all. But also less inconvenient. When you have to fill a prescription in the United States, you have to stand in line in a pharmacy. Your insurance might not cover it, there’s always a co-pay. There are perhaps times when those strategies are okay, but certainly not in the middle of a public health crisis.

Now, a little bit different question. If we had a universal medical education system in all countries, what will be its most basic principles?

Well, equity should be up there. I would say, if we used the term equity, as we do in talking about global health equity, you can design responses to health crises, or prevent them, in a more meaningful manner. For example, in Rwanda, again, there was a focus in those years when they were rolling out a national health insurance scheme, and national care delivery programs, there was more of a focus on rural areas than urban areas, and on the poorest people, rather than on the wealthy. On women and children, rather than just anyone. And that kind of design, which should be something you consider in any country, that kind of design made all the difference. And I just look back to my medical education at Harvard Medical School, and I know that I never learned anything about health insurance, I never learned anything about even how medical training is financed in the United States. It’s financed through a public insurance scheme called Medicare. I didn’t know that. And we learned absolutely nothing about health care financing.  So we graduated from one of the best medical schools in the world quite illiterate about these very important issues. And I think that we don’t want to do that again. It’s the same in nursing as well. Every health care professional should be at least literate in how equity might play a role in improving health for everyone. That’s just one example of the kind of general… I mentioned very specific things also, like health care financing. I don’t imagine that it’s a good idea to graduate from a professional school without, if you’re a nurse or a doctor, not knowing how it’s done. And there are many other things too. Obviously, we definitely want to continue investing in basic science that underpins so many developments in medicine. I think a lot of American schools do that fairly well, but if you could imagine a university or a medical school or nursing school where there’s a focus on equity, but also the science that underpins medical innovation, maybe you’ll come up with the kind of university that my colleagues in Rwanda founded, which we just named the University of Global Health Equity. And that was definitely the idea there, I can say, as someone involved in the founding of the university. And we hope that there will be many others like it going forward.

The last question: You are both a medical anthropologist and a physician. Has this multi-disciplinary interest broadened your horizons as a scientist? Would you recommend that young scientists diversify their interests?

I will just say this: I feel so lucky, to this day, to have benefited from training in anthropology. I mentioned that one of my mentors was a founder of Koç University, Nur Yalman. And I’ll tell you, I don’t know that this made it into the speech, but one of the classes I took from him was called “Social Theory.” And you’d never get a class like that in medical school, right? But it’s important to understand how the world works, how the social world works. Because that’s the world we live in. That’s the only one we know. And Harvard and a few other, not many, American universities have developed these programs that are MD-PhD programs in the social sciences. And the “social sciences” may include sociology, history. Some of my best colleagues at Harvard are historians who are also physicians. I’ve learned more from them, you know… When I think about epidemics, I go back to my colleagues who went through the same program and I learn from them every time. Economics. Again, physicians, and I’m among them, alas, are willfully ignorant about economics. But when you have more people who are trained jointly in these… One a profession, medicine, the other a discipline, let’s say, economics, sociology… We’ve had students who trained in the classics. And I just think it informs the entire experience. Now, I will say that Harvard is one of the places where a social medicine course is required in medical school. But every year we have to fight for the amount of time we get. If you imagine someone who is working on let’s say, CRISPR. I’m sure you’ve been writing about that. Or molecular biology of any sort. Wouldn’t you want that person to know more about the history of the development of that science? More about its implications in a very troubled but beautiful world? I would say yes, they would be better scientists if they knew more about the context around them, which is what anthropology looks at. But also the social history of the problem that they’re looking at. So I try to do that in my work, even though I’m not a historian. If I want to write a book about Ebola, you can bet that I’m going to go back to my historian friends and say, “How does this strike you compared to the other outbreaks of deadly viral disease?” It’s just something that everyone can do with a little effort, is understand the context around you and the history of how it came to be. As I said, I’m still excited about that approach, 40 years after first encountering it in the classroom.