One of the most prominent people in global health died last month.
Wikipedia makes it hard to see what Paul Farmer actually did, behind the mountain of honors and appointments he received for it (Harvard prof, MacArthur grant, UN envoy, etc). He cofounded Partners In Health, now a $100m+ per year organisation. PIH works in Haiti, Peru, Mexico, Russia, Lesotho, Kazakhstan, Rwanda, Malawi, Sierra Leone, India and Liberia, greatly upgrading the quality of healthcare near their operations, and doing a huge amount of welfare programmes besides.
They class themselves as a humanitarian organisation, though most of their work is not the crisis work you'd associate with that (except incidentally, as when an earthquake happened next to the hospital they were building).
They do a huge, huge variety of things, under the root-cause theory of public health, where stuff like good shelter and food is treated as part of healthcare. They started out doing HIV treatment - and once you're doing that it only makes sense to do HIV prevention - and after that you're kinda hosed. An incomplete list: "HIV treatment, tuberculosis treatment... food baskets, transportation, lodging... dirty water... from in-home consultations to cancer treatments... job skills training, small business loans... a university in Rwanda... the world's largest TB research study... biocontainment unit in Lima... allowing [children] to attend school and receive food".
Farmer's most notable work is being the single most powerful advocate for Haitian public health; PIH staff serve nearly half the entire country, and he was mates with Bills Clinton and Gates. Haiti will need another Farmer:
He was an anthropologist by trade. In the past I've gotten annoyed with anthropology for bad epistemics (or for conflating good epistemics and good activism). But it's hard to fault Farmer as exemplar of the general approach "don't just watch, do something".
I take his lifework to amount to the importance of operations. He didn't develop any vaccines or pills, he didn't make a pile of cash and give it away, and his research wasn't the main feature. Instead (as per Wikipedia) his org "created specific initiatives", "improved medical infrastructure" and provided "accompaniment rather than charity". (As with all large development organisations, they have their own homebrew intellectual framework, "Supervision-Partners-Incentives-Choice-Education".) Suitably unglamorous terms for good unglamorous things.
He was extremely good at getting powerful people to care. There's a whole book about him, and he has been widely elegised. This marks out his strategy as the prestige route, using the system. Near the ceiling of that approach, perhaps.
As usual in global health, most discussion of PIH's impact is actually about their inputs: number of staff, number of programmes, etc. (Not their budget though, which is both good and bad.)
GiveWell gave them an ultra-tentative recommendation in 2007, but this was largely on priors about good healthcare in countries with a shortage of it. ("We would guess that it is improving health outcomes") When evaluated properly in 2010, GW found that PIH weren't formally evaluating their own work and mostly wouldn't share their programme budgets, and so they couldn't give them the internalist stamp of approval. ("We would guess that they are outside – though not necessarily far outside – what we consider to be a reasonable range [of cost-effectiveness].")
- "focused on AIDS prevention during the HIV crisis and successfully decreased HIV transmission rates by 4% from mothers to babies"
- Built and run several hospitals, including 40% of Haiti's medical system. One nice feature: they're big on videoconferencing for American docs to train Haitian staff remotely.
- fighting tuberculosis outbreaks across the world
- I don't know how important his own research is. It didn't come up in my brief stint in international development.
The sheer variety of non-health programmes I mentioned above is usually a bad sign, but at least in Rwanda in 2010 about 93% of their spending was on health programmes.
As with most global health work, and even most good global health work, we can't easily say how much good they've done. It should be possible for someone to reconstruct the total impact of PIH given lots of time and effort. For now I'll just note that it's hundreds of millions of improved doctor visits and probably millions of QALYs lifted.
Epistemic status: Literally guesswork with two weak constraints.
>$100m a year now. But PIH were <$10m for the first 14 years. A crappy guess of their total lifetime spend is then $750m.
- He apparently subscribed to "liberation theology" (roughly: Catholic socialism). This is perhaps one of the larger anti-poverty movements in the world, but it has zero mentions on the forum, since it is triply distant from us: religious, Latin American, and politically activist.
- Another dedicated global health worker turned down his marriage proposal because he was too extra:
For a long time I thought I could live and work in Haiti, carving out a life with you, but now I understand that I can’t. And that’s simply not compatible with your life... the qualities I love in you — that drew me to you — also cause me to resent you: namely your unswerving commitment to the poor, your limitless schedule and your massive compassion for others. You were right, and, as your wife, I would place my own emotional needs in the way of your important vision; a vision whose impact upon the poor (and the rest of us) can’t be exaggerated
- His biographer:
I was drawn to the man himself. He worked extraordinary hours. In fact, I don’t think he sleeps more than an hour or two most nights. Here was a person who seemed to be practicing more than he preached, who seemed to be living, as nearly as any human being can, without hypocrisy. A challenging person, the kind of person whose example can irritate you by making you feel you’ve never done anything as important, and yet, in his presence, those kinds of feelings tended to vanish. In the past, when I’d imagined a person with credentials like his, I’d imagined someone dour and self-righteous, but he was very friendly and irreverent, and quite funny. He seemed like someone I’d like to know...