Faith in Things Unseen

Paul Edward Farmer

Paul Farmer was a friend to all of us, and we all have our memories with him. That was part of his exceptionalism; he developed strong, meaningful friendships with everyone. Although he was not a surgeon, he was one of us, and his patronage and mentorship allowed global surgery to grow and mature beyond what any of us imagined was possible. In 1980, Halfdan Mahler made a plea to the global health world, saying that poor access to surgical care was a social inequity. Then, for 28 years, little changed in the global health narrative, and surgical care was largely absent from the public health perspective.

In 2008, Paul Farmer and Jim Kim wrote a commentary in the World Journal of Surgery using a graphic metaphor that could no longer be ignored: they called global surgery the “neglected stepchild” of global health. What a bold statement to come from two infectious disease doctors who had devoted their lives to HIV, TB, and malaria. But that is not all they did—they also promoted and expanded surgical care delivery in their organization, Partners in Health, demonstrating without a doubt that delivering surgical care to the poor was not an impossible mission; in fact, they both made the argument that the very nature of true health equity and social justice demanded the inclusion of surgery and anesthesia. Maybe it was precisely for this reason—that global health leaders who were not surgeons had highlighted the pivotal role of surgery and anesthesia in equitable and just health care systems—that an environment emerged in global public health that would see a metamorphosis in global surgical care as an equal and valuable partner in health equity and social justice.

A few years later, Paul was a commissioner on the Lancet Commission on Global Surgery which was published in 2015 and defined a vision for global surgery and anesthesia, provided novel indicators and key messages, and ultimately called for all countries to define for themselves surgical, obstetric, and anesthesia strategic goals and objectives that were then fully integrated into their national health priorities. Paul spoke passionately about his commitment to equitable access to surgical and anesthesia care at the May 2015 Boston launch of the Lancet Commission [1].

This brief recounting of Paul’s allyship and accompaniment with our global surgery community does not do justice to the impact Paul had by leading, speaking, and advocating for surgery, nor does it recognize his behind-the-scenes advocacy for surgery and anesthesia as a global public health priority. Much of what Paul did for global surgery and anesthesia and all of us was unseen to the public eye, and yet we knew he was with us always—whenever we needed him, he was there.

Paul Farmer died on February 21, 2022, in Rwanda, doing what he loved the most—providing care to the poor and marginalized. None of us were prepared.

Several weeks after Paul’s passing, at a global memorial service in Boston at Trinity Church, eulogies were given by Anthony Fauci, Ophelia Dahl, Catherine Farmer (Paul’s daughter), and Jim Kim.

Jim Kim told us a story about his son Thomas, and Paul’s daughter, Catherine when they were much younger. They were arguing about a very complex topic; Catherine was trying to convince Thomas of God’s existence, and Thomas was unconvinced. He pointed out that no one has ever actually seen God. Paul overheard the two of them and told his daughter, “Remember Catherine, what I told you about faith in things unseen”.

In the days and weeks that followed the memorial service, Jim’s story about Thomas and Catherine forced me to think about Paul Farmer—the messenger, the message, and faith in things unseen. Paul was no longer with us, and that realization was disconcerting and destabilizing. Even if we didn’t see Paul for months or years, he had always been there for all of us. He was the bearer of “the message.” The messenger and the message were one and the same; the incarnation of the hope and the mission in which we all believed. And now he was forever to be “unseen.”

How ironic that Paul’s death occurred right before the Lenten season. Lent, the start of the Easter season for Christians, is about the death and resurrection of Jesus. In Catholic grade school, I was taught that Jesus died for our sins. That concept of Easter is based on humans as sinners needing redemption, and that message never resonated strongly with me. That view of the human condition always seemed negative and reductive.

When you consider Paul’s message about humanity, it was very different. He talked not about sin but service—service to address the tragedy of human suffering and the solutions found in equity and justice. Paul’s was a message of hope through action, a message of solidarity with those suffering and our obligation to accompany them. More specifically, he talked about “pragmatic solidarity,” not a hollow performative gesture but a durable commitment to others based on active accompaniment.

Another observation I made was that this year, shortly after Paul’s death, Easter, Passover, and Ramadan all coincided. All three religions simultaneously recognizing the importance of sacrifice, loss, penance, and reconciliation. A seemingly insignificant occurrence, however, what a remarkable metaphor for the universality of Paul’s life message and our collective re-acquaintance with it; a symbol of Paul’s “resurrection” within all of us.

So, was this timing just a coincidence? Maybe not? You have to admit that Paul was very persuasive; I would not put it past him to have orchestrated an arrangement with God around the coincident timing of his death and those three religious holidays.

In the aftermath of Paul’s death, we have all gone through a time of reflection. Reflection on the messenger and the message. I hope the concept of resurrection is a metaphor for the legacy that Paul left us and our realization of his vision, and our re-commitment to its purpose.

It is impossible to summarize Paul’s essence in words; however, let me share some of my thoughts held in an email that I sent to our Program in Global Surgery and Social Change team several days after Paul died.

I wrote the following:

I suspect that once in a millennium, God delivers to the world someone like Paul Farmer, and I fear that we will have to wait a 1000 years for another like him to come along. As tremendously nuanced as he was, there are three qualities about Paul that immediately came to my mind.

First, Paul had a special vision to see further into the nature of the human condition than any person of our time. He understood the history of humanity that laid the groundwork for the social construction of our present world, and he worked to change it. He had a timeless and dimensionless ability to understand our true human purpose and clarity and urgency for forward-facing action.

Second, his sense of compassion was limitless. The word itself comes from the Latin “passio” meaning to suffer. Thus, the word compassion means “to suffer with” another person, to understand it and feel it; however, more importantly, to be called to action because of it. An action that we learned from Paul to be a commitment to accompaniment. Paul spent his entire life in solidarity with human suffering, and his lifetime goal was devoted to its elimination.

Lastly, Paul was uniquely able to bring out the “better angels of our nature.” You always felt better after you were with him; better about yourself, better about the world, and better about the future. Whether it was with children, heads of state, or his favorite, with his patients, he could reach inside their souls to link them to our shared humanity. He instinctively understood what Mother Theresa once said, that “if we have no peace, it is because we have forgotten that we belong to each other.” Paul reminded us that we belong to each other and inspired us to do more, always, and for everyone.

There is no way to make sense of his passing; now or if he had lived another 10 or 20 years. The world needed him forever. However, I am certain that what he wanted for us is to live what we learned from him; to reach out, to be with, to help those, to always try, and to never give up.

So now it is up to us.

Jim Kim reminded us of Paul’s words to his daughter…AND TO US:

“Remember what I told you about faith in things unseen.”