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HumanitiesCMAJ

Partner to the Poor: A Paul Farmer Reader
Paul Farmer
Haun Saussy, Editor
University of California Press; 2010. 

D
r. Paul Farmer is an inspiration.
A physician specializing in
infectious disease as well as an

anthropologist, he was one of the
cofounders of Partners In Health in 1987
and has devoted his career to helping the
poor gain access to medical services and
treatment in Haiti, Rwanda, Peru, Mex-
ico, Russia and elsewhere. He is the
author of many influential books and
essays addressing the impact of what he
has termed “structural violence” (the
embodiment of poverty and entrenched
inequalities as violence) on the health of
populations against whom it is directed,
as well as a history of Haiti. He was the
subject of Tracy Kidder’s bestselling
biography Mountains beyond Mountains. 

Partner to the Poor is a compilation
of essays and talks given by Farmer
from 1988–2009. They are fascinating,
thought-provoking and, despite the fact
that some are over 20 years old, relevant
to anyone interested in global health and
issues related to its disparities. The
book’s four sections address the inter-
sections of anthropology and medicine
at different points: culture, history,
ethics, human rights; gender, racial and
political inequalities; and access to
health care and/or its denial. 
A prime example of the latter, dis-

cussed multiple times throughout the
book, is the rapid spread of AIDS in
Haiti and Africa during the 1980s and
1990s, and the various approaches sug-
gested for halting it. Many opposed sup-
plying affordable retroviral medications
to some of the hardest hit (and poorest)
parts of the world because it was not
cost-effective and because of concern
that there was insufficient infrastructure
in those places to ensure the necessary
adherence to prevent the emergence of

resistant strains of HIV. Those organiza-
tions preferred to focus their efforts on
prevention rather than on treatment. 
Farmer disagreed with this approach,

which, in his opinion, ignored the real
reasons for the spread of AIDS, namely
the socio-economic forces that had led to
the collapse of traditional agrarian soci-
eties, as well as entrenched poverty and
gender inequality, which were all beyond
the abilities of any of the organizations to
resolve quickly. Farmer and Partners In
Health successfully demonstrated that it
was possible to achieve real progress in
the fight against AIDS when combining
prevention with treatment. (Farmer notes
that those models that focused only on
prevention ultimately proved completely
ineffective.) 
Farmer also argues that properly

framing the conversations on how to
improve global health and defining their
context is critical to understanding the
challenges involved in doing so and
being able to overcome them. When
people defend a reluctance to introduce
antiretroviral medication to rural Haiti
and Africa because of the cost, he advo-

cates using that as the “beginning of a
conversation … [rather than] the end of
one.” Costs can be brought down, after
all, and effectiveness improved. 
He wonders how one can seriously

frame questioning the use of medications
not yet approved for use in children by
the US Food and Drug Administration to
treat multi−drug resistant tuberculosis,
which causes 500 000 new cases annu-
ally, as an “ethical challenge.” He points
out that this is in fact a litigious, not an
ethical concern, and that it does not
begin to consider the priorities of those
so desperately in need of treatment. 
Similarly, he refers to “the near

invisibility of the poor” when describ-
ing the reaction to a talk given at Har-
vard University by a Rwandan pediatri-
cian who was presenting the inroads
Partners In Health had made in treating
cancer patients in Rwanda. After con-
cluding his talk, the pediatrician found
himself “upbraided repeatedly about
ethical concerns regarding the delivery
of cancer care by people not trained in
oncology,” despite the fact that there
were no oncologists in the Rwandan
countryside and that the real alternative
was simply to provide no care at all. 
Farmer concludes one of the essays

by writing that “we have no more
excuses for ignoring the growing
inequality that has left hundreds of mil-
lions of people without any hope of
surviving preventable and treatable ill-
nesses.” This uncompromising commit-
ment to social justice, as well as the
dedication and steadfast resolve to
improve the lives of others are clearly
evident throughout the book and his
work at large. It is precisely these qual-
ities that have made him an inspiration
to so many across the world.

Dennis Rosen MD
Division of Respiratory Diseases
Children’s Hospital Boston
Harvard Medical School
Boston, USA

CMAJ • DECEMBER 14, 2010 • 182(18)
© 2010 Canadian Medical Association or its licensors

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Books

An uncompromising commitment to social justice

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