As a newly minted internal medicine physician, I found myself working in the cancer wards of a rural hospital in Rwanda. Despite our innovative approach to working in a resource limited setting, I quickly learned the long-term impact of inequities stemming from colonialism, structural violence, and other socioeconomic injustices.
At first, I had more patients die in a month than I did during my entire residency training, but this challenge was exactly what drew me to the work. It was 2013, and I was experiencing my dream job by working for the non-profit organization, Partners In Health (PIH). At the time, Paul Farmer, the co-founder, was living with his family in Rwanda, so it was not uncommon to run into him at the hospital or even round together on patients. While I was surprised by his wit and humor, even in the most difficult situations, I was not surprised to find him to be one of the most compassionate and technically skilled physicians. His broad range of questions delving into the social determinants of health with great precision allowed him to merge the social and medical pathologies that led to the patient’s hospitalization.
At the time, cancer patients in Rwanda all too frequently presented at such a late stage of the disease where palliative care was our only option. The causes of the health system capturing patients late were, in part, driven by a dynamic context of social and economic inequities, including limited nutrition, limited transportation, physical disability, and limited health education. For these reasons, even in cases where curing the cancer was possible, critics questioned why we would dedicate so many resources for chemotherapy, pathology, and international radiotherapy referrals in such a rural environment amongst such a vulnerable population. They argued that even with advanced medications, the socioeconomic barriers would prevent any possibility of positive, scalable health outcomes. Investing in the health of these individuals was seen as “not worth it.”
Paul Farmer and his colleagues started PIH in 1987 with an initial focus on the most vulnerable patients in rural Haiti. By prioritizing the most difficult to treat diseases, like tuberculosis and HIV, amongst the most neglected, they demonstrated that the idea of “health for all” is not a pipedream, but a responsibility. Too often, treatable illnesses among neglected communities are deemed as not “cost-effective” or brushed off as “that’s just the way it is.” Paul Farmer described avoidable deaths as “stupid deaths.” Driven by health equity, he called for a prioritization of the poorest communities facing the most challenges. Their model of supporting local governments to strengthen health systems among the most vulnerable communities would be replicated in resource-limited settings across the world, including the US.
Paul Farmer was not only a physician, but also an anthropologist which provided a unique platform from which he applied the historical and social injustices to describe both the structural cause of the illness but also the systemic solutions. This pushed PIH to not only support the establishment of strong clinics and hospitals, but also robust social support programs to ensure that the patients’ socioeconomic needs at home were fulfilled and allowed the medical appointments be met, medications to work, and the body to heal. Vital social programs included nutrition, transportation, housing, and financial assistance.
Prior to working at PIH, my journey to understand health inequity and cultivate a desire to fight was born out of anti-racism. Growing up in the US, I unfortunately learned firsthand the ugly truth of racism both as a victim as well as through long conversations with my father. He taught me the struggles and injustices that he has faced and that I would inevitably inherit. Furthermore, he taught me the plight of immigrant families and other marginalized communities. As with Farmer’s anthropologic lens of health disparities, AAPIs have been marginalized by racist policies around forced internment camps and immigration restrictions, a racist justice system (e.g., murder of Vincent Chin), and surges in physical assault that continue to affect our capacity to live healthy, equitable, and fulfilling lives. That said, the brutal realities of systemic racism have made me the fighter against health inequities that I am today. Fighting against health inequity in Washington or any low-income country is inherently rooted in anti-racism.
On February 21, 2022, Paul Farmer passed away in the same rural district where we first worked together in taking care of cancer patients. PIH had since built a medical school there, so he was doing what he loved: teaching global health to Rwandan medical students that would continue the health equity approach for the people of Rwanda and beyond. Paul inspired innumerable pupils, colleagues, and friends to accept the responsibility of health equity and dedicate their lives to this vital cause.
In my last encounter with Paul, while he was sad to see me leave PIH, he was genuinely excited for the opportunities that lay ahead to apply the valuable lessons and tools of health equity to Lifelong. He understood that Lifelong’s mission, like his, sought to address social injustices, like racism, amongst the most neglected so that they, like anyone, could have the dignity in achieving their best health.
As I was able to contribute to the Government of Rwanda’s successful health outcomes in cancer care, I am honored to carry on Paul’s legacy of health equity by prioritizing the most vulnerable communities in Washington. I know that he would be proud to see me leverage on my AAPI identity and lived experiences surrounding racism to engage with government and community partners and address the unique needs of BIPOC, LGBTQ, and other neglected communities. Avoidable “stupid deaths” from cancer, diabetes, cardiovascular disease, chronic kidney disease, COVID-19, HIV, and others do disproportionately occur among these communities in Washington, and Lifelong seeks to strengthen the health system’s ability to create vital avenues to access essential social and health resources.
This month, Lifelong will share the unique health challenges faced by the AAPI community and how we can prioritize them. Paul Farmer framed the power of equity well when he reminded us: The idea that some lives matter less is the root of all that's wrong with the world.