In Memoriam: Remembering Drs. Paul Farmer and Mark Jacobson

This week saw the unexpected passing in Rwanda of one of the true giants of global medicine, Dr. Paul Farmer, co-founder of the respected humanitarian medical organization Partners in Health and a pioneer in the treatment of tuberculosis and HIV in resource-limited settings. The entire AMH family extends its condolences to his family and colleagues.

While a visiting medical student at Harvard in 1999, I had the good fortune of spending two days rounding with Dr. Farmer. I had always hoped the opportunity to do so would come again.

Over 20 years later, those two days still stick in my mind. I had never heard of Dr. Farmer before. He was not as famous back then, prior to the publication of Tracy Kidder’s Mountains Beyond Mountains. The residency program director told me that I must meet him, given my interest in global health. Next thing I know, I’m on the phone with Dr. Farmer and then rounding with his team. (At the time he was an attending physician on the infectious diseases service at Brigham and Women’s Hospital and split his time between Boston and Haiti.)

He spent so much time talking to me and including me — a medical student, not even from Harvard, just summarily dropped on to his busy service — that I wondered, “Doesn’t he have other things to do?” When I read the reminiscence this week of Dr. Paul Sax, also an infectious diseases doctor at Harvard, those two days came back to me:

One of Paul’s great talents was making you feel important…It didn’t diminish the experience one bit that he made everyone feel important — when he was talking to you, looking at you, he had you front and center in that big generous heart of his, and everyone else drifted away.

It wasn’t just me. He treated everyone like that.

The other impact on my life wrought by that brief experience was his answer to my simple question, “What do you do in Haiti?” “Mostly, I do clinical work.” He actually treats sick people! That answer might seem mundane and obvious. For those of us working on the ground in Africa, it’s anything but expected. In medical school, and later in residency, and still later in Africa, I learned that most Western academics involved on the continent did research. And little of this research made its way to the village level.

Still to this day I am not sure how many of Dr. Farmer’s well-deserved fans realize why his approach was so revolutionary: he treated sick people. Don’t assume that is what foreign aid staff and university professors and NGOs and big donors are actually doing most of the time in Africa. It isn’t (with some notable and valuable exceptions). Yes, we need research. I try to incorporate new findings in my care and teaching regularly. But actual treatment of patients always gets the short end of the stick in this setting. We have a serious “last mile problem” in the form of a failure to deliver care to those who need it most.

Dr. Farmer’s example inspired a number of organizations trying to expand access to actual medical care, quality care, dignified care, such as Muso, Possible, Dignitas, Build Health International and even African Mission Healthcare. We need 10,000 such organizations. Literally.

Dr. Farmer once gave a lecture addressing the ”know-do gap”: We know what to do, but we just aren’t doing it. Less than 3% of African kids have access to safe surgery. There simply isn’t a technological solution to this problem (outside of anesthesia and sterile technique, discovered in the mid-19th century). We have to do, we have to implement. Two years ago Dr. Farmer and colleagues wrote in The New England Journal of Medicine about the dilapidated state of the “neglected district hospital.” It really seems, based on the amount of press coverage, that the answer from much of the Western philanthropic-aid-investor class is that we are going to solve this problem with drones. Maybe apps. Or robots.

Dr. Farmer knew otherwise. He knew it was going to be a lot harder than that. Yet he was also an optimist — with good reason! And he dedicated his life to that vision. The world has lost a giant. It’s the task of all of us to continue the work.

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Two weeks ago, African medicine lost another hero, although one less well known than Paul Farmer. Dr. Mark Jacobson, gentle and unassuming, would never consent to being called a hero, but he was one. Mark spent the better part of four decades in Africa, mostly in northern Tanzania. His obituary describes some of the accomplishments:

He grew a one-room clinic into two nationally recognized hospitals, and as health needs in the area changed, he developed programs around HIV/AIDS, obstetric fistula repair, palliative care and hospice, cancer care, and medical training.

Let us add to this list a nursing school that is giving young Maasai women a professional career and a bright future.

Originally, I had wanted to work with Dr. Jacobson, but that turned out not to be possible. I wound up in Kenya instead. When we started AMH in 2010, the first person I contacted was Mark. I wanted to support his work. I wanted to be a vicarious part of what he was doing. AMH had the privilege over a decade to partner with Arusha Lutheran Medical Center in a number of areas.

Mark represented some of the best traditions of missionary medicine: an unshakeable, long-term commitment to developing, step-by-slow-and-painful-step, local healthcare capacity in a specific region, partnering with and ultimately handing over to local people.

Rest in peace, good and faithful servant (Matthew 25:21).

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In residency we used to talk about “the days of the giants,” a reference to a mythic physician of the past who was pioneer, teacher, researcher, and clinician, someone who could “do it all.” Whether those people ever existed, I don’t know. What we ought to refer to is the giants walking amongst us, the ethical giants, whose legacy is not measured in reputation but in human lives, in hope, and in dignity.

Yours in Struggle,

Jon Fielder, MD

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Dr. Jon Fielder is a medical missionary in Kenya and directs African Mission Healthcare, which strengthens mission hospitals to help patients in greatest need. This work may be supported here.