A Legacy of Innovation, Fractal Thinking, and Health Equity

Introduction

Like many in the global health community, I was stunned by the sudden death of physician-anthropologist Paul Farmer this week. The leading voice for challenging traditional thinking in healthcare, he was known for demanding that health systems can do better at providing high quality care for the poor around the globe. Viewed from a distance, his work was often seen as charity; however, this falls short in understanding the impact that Farmer and the organization he co-founded, Partners in Health (PIH), had on healthcare delivery, the meaning of innovation, and an anthropological approach that was not afraid of attacking sacred cows.

American health technology could use some Paul Farmers these days. He was not afraid of speaking out against the donor community when necessary, as well as debunking the simple explanations of behaviors of the poor that occluded the complex histories that produced the poverty that drive epidemics and unnecessary deaths. As we look at the state of rural health in the US and the decreasing access to tertiary care in many communities, Farmer would not shy away from pointing out the role of private equity firms in producing health inequalities and poor outcomes, as just one example among many.

Farmer’s Critical Thinking

In discussions on social determinants of health (SDoH), it has become commonplace to embed the chart showing that most of our health outcomes are driven by social and environmental causes, and that medical care is only 20% of the overall outcome. This is true. But Farmer would also say that care does matter quite a bit for the poor. He would warn against the tendency to deploy reductionist thinking as we see so often in economics. Instead, he called for “fractal thinking” or the need to think along multiple registers and scales at the same time.

Food deserts are a major problem in many cities. Farmer would not just focus on the singular food desert but try to think about food systems and how to improve them in a systemic way for the poor. He would write about the “adjacent possible” and the innovations that could be made accessible to many. Even if one disagreed with Farmer, the process of engaging with his thinking was educational and enlightening.

In the area of multi-drug resistant tuberculosis control, we saw some of the clinical and public health thinking come together and deeply challenge the traditional medical community, economists, and policymakers. The traditionalists had essentially written the poor off to die when Farmer and his PIH colleagues fought to give the poor in Peru access to expensive drugs reserved for wealthier countries. PIH found that the drugs were off-patent and the prices could be reduced by 90%, while policy-makers dithered and fabricated lame excuses for inaction (remember Andrew Natsios [Administrator, USAID] testifying that Africans did not have watches?). This became the model for distributing anti-retrovirals (ARVs) to the countries hit hardest by HIV that saved millions of lives.

When ARV users needed to have sufficient diets, PIH created their accompaniment program that also provided food so that the drugs would not be toxic to the users. Many patients in Haiti were nearly brought back from the dead. Many other programs and donors, surprisingly, would have viewed such a program as too complex. We need to find simple solutions, they argue. These programs are too expensive, non-replicable, not enough data. Does this sound familiar?

Farmer’s Lessons and Legacy

Always challenge the dominant mindset and ask questions, even if they are uncomfortable. In West Africa (Liberia and Sierra Leone) during the largest outbreak of Ebola that we had experienced up to this time, we saw large humanitarian organizations fly in to respond to the crisis. They provided critical medical care to those suffering. However, there were some issues with how they emphasized containment and quarantine over providing the highest standard of care to those suffering. Farmer challenged this thinking, and lives were saved by successful fluid resuscitation.

Many in the media focused on cultural practices and the “bleeding out” of patients which portrayed another horrific, exotic disease and zombie-like sufferers. In Fevers, Feuds, and Diamonds, Farmer reminded us that most sufferers did not bleed out and could have high survival rates with the appropriate care. Ebola spread, not by bizarre burial rituals and eating bushmeat, but due to poorly funded public health systems. These insights came home globally when SARS-CoV-2 laid bare the decades of neglect of public health by many countries, including the US.

Farmer died in Rwanda, where he and PIH had been working for close to two decades. I worked in Rwanda in the years after the genocide, and many of the innovative approaches utilized by Rwanda now were almost unimaginable in the mid-1990s. A country where nearly 1 in 7 was murdered and 1 in 3 became refugees in 100 days during 1994, now has drones that can deliver drugs, while also employing universal cancer screenings for metastatic cervical cancer after a survey indicated high prevalence rates. The entire population of 12-year-old girls was vaccinated to prevent cervical cancer. Farmer was fond of saying it was all about “Staff, stuff, space and systems.” Rwanda illustrates how this worked in practice; they experienced the steepest declines in in mortality ever seen in Rwanda. “Optimism is a moral choice,” he once said.

Conclusions

I recently spoke on AI, SDoH, and health equity at a WEDI sponsored event on health equity, several days before Farmer passed away. We spoke about the usual cast of AI sins, from bias to data science mistakes that can lead to models gone awry. All of these issues can erode trust in medicine and healthcare institutions, especially when taken within the long view of our history. From Tuskegee to Hurricane Katrina, institutional failures dot the landscape, and even up to our present pandemic that is rife with such failures over the past two years.

When responding to these crises, we too frequently reach for the usual set of tools in our bags: “Let’s do an RCT to see if this intervention works or is replicable.” This is important, but those same tools can blind us to critical thinking skills that often uncover other ways of doing things that could be more effective at improving health outcomes. Reductionist approaches have their place, but Farmer also showed their weaknesses. We sometimes suffer from the poverty of imagination and lack the fortitude to challenge the orthodoxies that structure what we think is common sense. Farmer illustrated the power of not only compassion, but also the power of anthropology when combined with medicine and public health to solve problems.

When I taught in the university in the 1990s, I had the opportunity to occasionally teach medical students who had an interest in Farmer’s work and in taking an interdisciplinary view of medicine. I have little doubt that these individuals became excellent physicians. Today, we have the field of data science and the rise of AI in virtually every aspect of our lives. Checklists of ethical issues to address may help, but the value of social science insights in our population health management, SDoH and health equity initiatives is vital as well. Even if it makes things harder for a time, Farmer showed how that hard work can scale and make a huge impact at a societal level. Thinking systemically and critically and using our medical and analytical tools to attack root causes can change lives, as Farmer showed repeatedly. His voice and wisdom in the medical community will be sorely missed.