An antidote to despair: Paul Farmer’s theology of accompaniment

By Isaac Holeman, 5 May 2022
The late physician, medical anthropologist and social justice advocate, Dr Paul Farmer. Image: Skoll Foundation/Wikimedia Commons
“Dear Polo, we miss you,” wrote a Haitian health worker some twenty years ago, to the physician and medical anthropologist Paul Farmer. “We miss you as the cracked dry earth misses the rain.” At the time Farmer reportedly commented, “After thirty-six hours? Haitians, man. They’re totally over the top. My kind of people.”

When Paul Farmer passed away in February at the age of sixty-two, the deluge of tributes on social media and major news outlets reminded us that his kind of people could be found in every place he had gone—and in some places where he hadn’t. Young and old, rich and poor, atheist and Hindu and Catholic, people from many walks of life took inspiration from Farmer’s quest to cure the world. Our aim, as he once put it, “is nothing less than the refashioning of our world into one in which no one starves, drinks impure water, lives in fear of the powerful and violent, or dies ill and unattended.”

Like many of the other people Farmer mentored, I discovered his work by way of Tracy Kidder’s inspiring biography Mountains Beyond Mountains (2003). Hearing about the book as a college freshman, I put it on my birthday list and received it as a gift that May. I recall sitting down to read it one morning and finishing late in the evening of the same day. My eyes were aching, yet somehow I felt more energetic than I had in years. It was my first exposure to the idea that poor health is a kind of social injustice, and it gave me new eyes for the story of my brother, who was adopted from an orphanage in Guatemala City when he was four. Kidder’s book also offered an irresistible image of Farmer as a real, imperfect, modern, funny, endearingly human person, one who was pursuing what seemed to me a saintly life. The book was just a snapshot of that life, and no doubt it concealed as much as it revealed. But anyone who read it would want to know more, and by the end of that summer I was deep in the pages of Farmer’s own books.

I was not often taken to church as a child, and, perhaps for that reason, I was slow to appreciate the reverent, almost devotional quality of Farmer’s following. Obituaries described him as a “giant of public health,” the world’s “most extraordinary medical humanitarian.” Bill Clinton said he was “one of the most extraordinary people I have ever known.” James Dear, a Jesuit priest who knew Farmer for decades, has argued that the Church should recognize him as a saint. On Twitter, the indie rock band Arcade Fire wrote that “Paul Farmer changed our lives forever. He showed us how to work harder for others than for yourself. He was the punkest mother f***er WE ever met. Steal from the rich and give to the poor. Make yourself useful. WE will keep fighting for Haiti until the end of time.”

Many of the tributes published since Farmer’s death celebrate his bedside manner and his work as a builder of hospitals, health systems, universities, and the movement for health equity. How on earth did he do it all? With the help of many others, as he was always quick to recognize. But then why did so many people want to help him? How did he spark such an earnest moral reckoning among such a diverse and devoted following? I believe we can begin to answer this question by turning to his own writing.

Farmer’s scholarly writing spans several decades and a few different academic disciplines. Some of his books and articles are more approachable than others. Farmer’s writing is often personal, describing the world as he saw it and walking readers through his own surprises, setbacks, and delights. Years ago, as I began to make my way through his books and scholarly articles, I discovered that his writing is unambiguously Catholic. He was not just a good Catholic who also happened to be a very good doctor, nor was he simply motivated by his faith to produce compelling secular ideas for a secular milieu. In order to understand his books and grasp the full power of his moral vision, I discovered I would need to study not only ethnography, infectious-disease ecology, and systems design, but also the gospels. I would also need to understand the emergence of liberation theology as a countercultural movement within the wider tradition of Catholic social teaching. These sources seemed to be an indispensable context for Farmer’s writing, first because he referenced them frequently, but later because my increasing exposure to Catholic social thought allowed me to read between the lines of Farmer’s work and see a deeper meaning in his project. He used the resources of the Catholic tradition to understand human suffering, to rebuke the principalities and powers that maintain the sorrows of the poor, and to nurture the fierce hopefulness for which he was so well known.

 

“Bearing witness” is a term with deep religious roots that were lost on me when I first encountered it in Farmer’s 2003 book, Pathologies of Power: Health, Human Rights, and the New War on the Poor. The first part of this book bears witness to poverty and poor health in Guatemala, Mexico, Haiti, Cuba, and Russia. In one instance, Farmer and Ophelia Dahl, co-founders of the health-care charity Partners In Health, found themselves in northern Guatemala. A local indigenous organization had requested their assistance for a mental-health project. The aim was to locate and disinter people whom the Guatemalan army had buried in mass graves during the country’s thirty-six-year civil war. Why?

Because the victims had been “buried with their eyes wide open.” And neither they nor their kin would know peace until they were buried properly. “So that their eyes may close,” explained Miguel, who, along with Julia, spoke as their leader. My own eyes were stinging, but not from the smoke. Again, a silence fell over us, this time a silence of complicity and solidarity. Ophelia spoke first, saying that we who would never know their suffering would try to do our part, and also that we would bear witness in the hope that such crimes could not be committed so readily in the future.

This scene beautifully conveys Farmer’s humanizing vision of health equity. Here to “bear witness” is a pragmatic expression with broad appeal. Yet Farmer did not shy away from the term’s religious roots, though he addressed the issue ethnographically rather than philosophically, by reflecting on the faith of the people he encountered in his work. In the following paragraphs he describes looking up from this meeting to see a small portrait of the recently martyred Bishop Juan José Gerardi, who was bludgeoned to death in 1998 after releasing a report that indicted the Guatemalan army for deaths and disappearances during the conflict. Farmer quotes the bishop’s final speech before his death:

In our country, the truth has been twisted and silenced. God is inflexibly opposed to evil in any form. The root of the downfall and the misfortune of humanity comes from the deliberate opposition to truth, which is the fundamental reality of God and of human beings. This reality has been intentionally distorted in our country throughout thirty-six years of war against the people.

The impulse to blame the poor for their problems is often connected to claims among the wealthy and powerful that we have little obligation, and perhaps little ability, to come to their aid in solidarity.

Here we find a more biblical injunction against bearing false witness, not in Farmer’s own words, but in a prophetic voice that he wanted us to hear.

“Structural violence” is one of the concepts Farmer relied on to make sense of poor health in such circumstances. To grasp the power and importance of this concept, we must first acknowledge that the poor are very often blamed for their own plight, as if personal choices or cultural differences could explain their condition. In the 1999 book Infections and Inequalities, Paul writes:

The most frequently encountered and easily circulated theories about women and AIDS are far more likely to include punitive images of women as purveyors of infection—prostitutes, for example, or mothers who “contaminate” their innocent offspring—than to include images of homelessness, barriers to medical care, a social service network that doesn’t work, and an absence of jobs and housing. Dominant readings are likely to suggest that women with AIDS have had large numbers of sexual partners, but are less likely to show how girls…are abducted into the flesh trade.

The way scientists and the media portray people living with HIV has improved since those words were written, but the underlying problem remains. As Farmer observes in his 2020 book, Fevers, Feuds, and Diamonds: Ebola and the Ravages of History, “discussions of epidemic disease in Africa make frequent use of the colonial era’s exoticizing language: game becomes ‘bushmeat,’ burials become ‘funerary rituals,’ and the terms ‘traditional’ and ‘native’ appear regularly, in proximity to each other, as code for ‘primitive.’” The impulse to blame the poor for their problems is often connected to claims among the wealthy and powerful that we have little obligation, and perhaps little ability, to come to their aid in solidarity. Farmer’s distinctive way of writing about the ravages of history forcefully dispels these myths. Centuries of slavery, resource extraction and ecological devastation, predatory international trade and debt policies, foreign support for violent dictators, and a raft of other obviously global problems create the conditions for Ebola, HIV, opioid abuse, and all the other modern plagues. “Structural violence” is one way of describing how these wider economic forces and ongoing social arrangements—systems we are all caught up in—put people in harm’s way. In “Health, Healing, and Social Justice: Insights from Liberation Theology,” which originally appeared as a chapter in Pathologies of Power, Farmer explains how liberation theology shaped this line of thinking, noting that what he calls structural violence has been described by many Latin-American priests and bishops as structural sin. Farmer cites Jon Sobrino, who describes such sin as an “absolute negation of God’s will.”

Understanding how large-scale social phenomena like sexism, racism, and poverty become evident in the failing health of oppressed people is particularly important when no individual wrongdoer can be singled out as the perpetrator of any particular act of violence. As Farmer would often say, real service to the poor involves understanding global poverty. He brought this insight to bear on his work with Partners In Health (PIH), whose mission statement bears quoting in its entirety:

Our mission is to provide a preferential option for the poor in health care. By establishing long-term relationships with sister organizations based in settings of poverty, Partners In Health strives to achieve two overarching goals: to bring the benefits of modern medical science to those most in need of them and to serve as an antidote to despair. We draw on the resources of the world’s elite medical and academic institutions and on the lived experience of the world’s poorest and sickest communities. We are dedicated to providing the highest level of clinical care possible while alleviating the crushing social and economic burden of poverty that creates obstacles to health. At its root, our mission is both medical and moral. It is based on solidarity, rather than charity alone. When our patients are ill and have no access to care, our team of health professionals, scholars, and activists will do whatever it takes to make them well—just as we would do if a member of our own families—or we ourselves—were ill. We stand with our patients, some of the poorest and sickest victims of poverty and disease, in their struggle for equity and social justice.

Farmer always described PIH as a secular organization, yet this mission statement’s opening mandate—to provide a preferential option for the poor—is a straightforward affirmation of liberation theology’s central teaching. While liberation theology has sometimes been controversial within the Church, the preferential option for the poor has always been widely embraced, in part because there is such clear precedent for it in the gospels—and, specifically, in the example of Jesus. The preferential option means something more than giving people things. It means standing with the poor in solidarity, whatever the cost. As Archbishop Óscar Romero put it, “there is a criterion for knowing whether God is close to us or far away: all those who worry about the hungry, the naked, the poor, the disappeared, the tortured, the imprisoned—about any suffering human being—are close to God.” An undergraduate at Duke University when Archbishop Romero was martyred, Farmer often mentioned how greatly this event affected him. As James Dear recalls in his February 23 America magazine tribute, “He attended the little prayer vigil that night on the campus, and as he later told me, it felt as if the scales fell from his eyes; he suddenly realized that to be a Christian meant you had to be on the side of the poor and to serve Christ in the poor.”

 

For Farmer, accompaniment was not only what desperately ill patients needed, it was also the kind of consolation and insight he found in the work of theologians like Gutiérrez.

PIH has provided a preferential option for the poor in many ways, and one strategy in particular has come to define the organization’s inspiring global impact: making community health workers central to care delivery. Community health workers (CHWs) are trusted neighbors who live in the communities they serve, and under the same circumstances as their patients. When equipped with a few months of on-the-job training, good supervision, a living wage, supplies, and strong connections to local clinics, CHWs can make a remarkable difference for people who face barriers to health care. PIH conducted the first studies to demonstrate that, with the support of CHWs, people in the poorest places on earth could complete complex treatments for afflictions such as HIV and drug-resistant tuberculosis and achieve cure rates on par with those in the United States. Since then, study after study has confirmed that CHW programs are exceptionally affordable ways to improve health outcomes in poor areas. What makes a good CHW program successful is not any one clinical practice. The model is based on wrap-around social support—on making house calls, being available to come running when called, advocating for patients as needed. PIH’s community health workers in Haiti are called accompagnateurs, because they accompany patients in the journey to good health.

 

The theme of accompaniment permeates Farmer’s work but is perhaps most evident in his 2013 book In the Company of the Poor: Conversations with Paul Farmer and Fr. Gustavo Gutiérrez. Gutiérrez is regarded by many as the father of liberation theology, and this book offers an intimate view of his decades-long friendship with Farmer. In the introduction, Michael Griffin and Jennie Weiss Block explain that Farmer and Gutiérrez both subscribe to what they call a “theology of accompaniment.” Later in the book, Farmer explains what Fr. Gustavo’s theology and accompaniment meant to him:

 

I was surrounded in central Haiti by something that felt violent and oppressive—namely, deep poverty and the tail end of the Duvalier dictatorship. Violence was both everyday and structural—in the words of one woman I met: it was the fight for wood, and water, and food. The people with whom I stayed lived in a squatter settlement because some of them had been displaced by a hydroelectric dam. This was their experience of structural violence. How does one make sense of this landscape of violence as a twenty-three-year-old American? I read a lot about the history of Haiti. I read great books that were about Haitian culture, including one about that particular valley where I lived, but I really took a lot of consolation from Gustavo’s work.

In another part of the book Farmer remarks,

As long as poverty and inequality persist, as long as people are wounded and imprisoned and despised, we humans will need accompaniment—practical, spiritual, intellectual. It is for this reason, and for many others, that I am grateful for Father Gustavo’s presence on this wounded but beautiful earth.

For Farmer, accompaniment was not only what desperately ill patients needed, it was also the kind of consolation and insight he found in the work of theologians like Gutiérrez. Accompaniment was also how Farmer talked about his relationship with students like me.

In A Theology of Liberation (1988) Gutiérrez writes that “if there is no friendship with the poor and no sharing of the life of the poor, then there is no authentic commitment to liberation, because love exists only among equals.” When I read this, I recalled the time Paul Farmer had affectionately called me an idiot for asking him to autograph a copy of In the Company of the Poor that he had given me as a gift. We laughed as he showed me where he had already signed it. I sensed that the tone of my question had put him on too high a pedestal. He wanted friends, not fans. Paul had many friends in the universities and the halls of power, but he wanted to make friends in the squatter settlements of the world, too. This interpersonal philosophy may help explain his radical rejection of material comforts. Many, including his biographer Tracy Kidder, seemed amazed at how long this esteemed Harvard University professor lived in a small home in Haiti with a tin roof and no hot water. People who knew him could tell you many similar stories: how he slept in a church rectory to save money during medical school; how he sent his paychecks to PIH only to go broke himself; how he skipped lunch because he’d given his meal to a homeless man; how he needed to borrow socks from a friend because he’d been traveling too long and simply ran out. He was like a twenty-first-century mendicant in travel-worn suit and tie. If Paul’s ideas were deeply Catholic, so were his sacrifices, and his humanizing way of life—as he would put it, totally over the top.

 

Let’s return to the question with which we began: how did Paul Farmer find himself at the center of an extraordinary global movement for a more humane world? It’s unlikely he could have attracted such a devoted following through works alone, by brilliance or work ethic or luck. The dean of Brown University’s School of Public Health, Ashish Jha, got closer to the mark when he claimed in the Atlantic that Farmer redefined the global health field to make it more human, in part by being so wonderfully human himself. Bill Gates wrote that there will never be another Paul Farmer. That’s true in a certain obvious sense, but we do ourselves and Farmer a disservice if we assume that he was simply born that way, that he was so very much better at being good than very nearly everyone else we’ve met, as if virtue were a quirk of personality. To call him a saint is perhaps no less extravagant a claim, yet thinking of him in this way places him within a group of other wonderfully human people, and suggests something important about how he became who he was. I believe that Farmer chose his way of life, and that he understood it in spiritual terms. If we dare to challenge ourselves the way Farmer often challenged us, we could acknowledge that each of us has opportunities every day to make decisions that would turn our lives in a direction more like his. Farmer’s books still provide important signposts for the journey. They are now, sadly, the only way we can still call on Farmer to accompany us in our struggles.

Or so I thought, when I started writing this article. A few days after Farmer died, a dear friend sent me a message to tell me he had been thinking of me. He said, “I know Paul would fully expect us to continue walking together. I also believe he equipped you, and all of us, and will continue to do so, for this journey.” That friend and I co-founded Medic together many years ago, a global health non-profit that—like Muso, Pivot, GlobeMed, MASS Design Group, Community Health Impact Coalition, and many others—was inspired by Farmer and only possible because of his pragmatic solidarity.

I was still pondering this message a week later, as I was working on this article. It was Ash Wednesday, so I had gone to Mass and was picturing where this journey had taken me—around the world and back many times, to St. Gabriel’s Hospital in rural Malawi, among other places. We launched Medic’s first project there, and it was in that hospital that I had really learned to pray. Eventually I was baptized in the hospital’s little chapel. Just over a decade later, as my local parish prayed to “all the angels and saints,” I realized that I was picturing Paul’s face. And then, reluctantly, I understood that Doctor Paul would still accompany me in prayer, should I find myself facing down a failure of imagination or striving for an antidote to despair. In the grief at his passing, many of us have wondered how the movement for health equity will go on without his tireless accompaniment. If we were to ask him, there’s a chance he’d say, with a wink and a smile, that he’s passed another mountain top and is just getting started.

Published in the May 2022 issue:

Isaac Holeman is an entrepreneur, writer, and human-centered designer based on a little farm in British Columbia. You can read more about his work or get in touch at https://isaacholeman.org.

With thanks to Commonweal Magazine where this article first appeared.
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