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Pathologies of Power: Health, Human Rights, and the New War on the Poor

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Paul Farmer's "Pathologies of Power" will probably give you a headache, undoubtedly cause sleep disturbance, and very likely turn your stomach. In short, it will make you sick. But if you are well enough to read this and rich enough to consider purchasing the book, you are better off than the "disposable millions" whose lives he illuminates and honors in this indictment of global public health as-we-know-it. In this passionate and well-researched treatise, a world-class physician takes his own disciplines of medicine and anthropology to task for failing to ask the right questions. Then, noting that the U.S. pharmaceutical industry is the most profitable industry in the most affluent country in the world, he blows through its defense of those extraordinary profits like a gust of fresh air. A similarly searing deconstruction of health policymakers' rationale for "cost-effectiveness" and their elite argot of oppression reveals a blame-the-victim mentality that plagues the world and explains why, in the midst of unprecedented wealth, over 40 million Americans are without health insurance of any kind. And that is just the beginning.

While Farmer's hospital in Haiti, Zanmi Lasante, is not the only hospital to successfully combat the forces of poverty and disease in that country (Hôpital Albert Schweitzer in the Artibonite Valley predates Farmer's project by nearly three decades), his twenty-year presence in Central Haiti has resulted in a deep understanding of how structural violence on a global scale is a leading cause of disease and death among the world's poor, wherever they may live. Drawing on case-study examples from Haiti, South America, Cuba, Siberia, and the United States, he deftly illustrates why tuberculosis deaths, which he describes as 95 percent curable with inexpensive medication developed many years ago, "occur almost exclusively among the poor, whether they reside in the inner cities of the United Stated or in the poor counties of the Southern Hemisphere." Addressing the growing trend of multi-drug resistant strains of TB, Farmer discusses "tuberculosis as punishment" in the world's prison populations and delivers a wake-up call to those who might consider themselves immune from this, and other, infectious diseases.

In his critique of the commodification of healthcare, Farmer speaks of "orphan drugs" drugs that are simply not developed because they are needed by people who cannot pay for them, the sale of organs by those without resources to those with money, and the equally revolting multi-million dollar compensation packages of pharmaceutical company CEOs and managed care executives. In the midst of this catalog of inequity, he wonders why medical ethics courses in American schools of medicine focus so narrowly on the "quandaries of the fortunate" like whether or not to refuse a particular technology or whether or not to leave a loved one in a prolonged coma when millions are condemned to death or disease before they learn to walk. Even the World Health Organization (WHO) does not escape his critical analysis: "... the language of social injustice is increasingly absent from public health parlance," he notes.

Farmer is one of those remarkable doctors working in remote places who, somehow, finds the energy to look up from his daily workload and ponder the underlying causes of the suffering he treats. Furthermore, he writes about it in the brisk and engaging prose of an investigative reporter and brings provocative interdisciplinary voices of others---Gustavo Gutiérrez, Paolo Freire, Cornel West, Amartya Sen, Jon Sobrino, Nancy Scheper-Hughes, to name a few---to bear on his march toward social justice. His ideas are radical, in part, because they are simple and based on an equitable distribution of health, regardless of wealth. Bringing the observe, judge, act methodology of liberation theology to bear on global public health, Farmer advocates a "preferential option" for the poor, a redefinition of medicine as a healing profession (as opposed to medicine-as-commerce), and a new understanding of healthcare as a basic human right, for all.

Toward the end of a chapter entitled "Listening for Prophetic Voices," Farmer distills his argument into a call to action: "We thus find ourselves at a crossroads: healthcare can be considered a commodity to be sold, or it can be considered a basic social right. It cannot comfortably be considered both of these at the same time. This, I believe, is the great drama of medicine at the start of this century. And this is the choice before all people of faith and good will in theses dangerous times."

Pathologies of Power is a lucid and alarming statement from a fearless physician. It speaks truth to power and it speaks for the destitute sick. Take two aspirin, lie down, and read the book. In spite of its consciousness-raising side effects, this may be the beginning of a cure for what ails the world.

There are some books whose message is so pertinent to your daily life that they stay with you for a long time. Farmer's PATHOLOGIES OF POWER will have a profound impression on you. Its substance is highly relevant for current topical debates, whether on Medicare and the forty million uninsured in the US, the Canadian government's ambition to "fix" healthcare or on strategies to fight health pandemics like HIV/AIDS. Farmer submits an emphatic challenge to the medical profession, to political and business leaders, mainstream media and all of us.

Farmer stands emphatically on the side of the destitute, marginalized and usually overlooked. His vivid case studies exemplify the fate of millions of "nobodies" - the silent majority of the world's population who have none or inadequate heath care. Why, he asks, are health care services not made available to all human beings irrespective of race, gender, locale, or the ability to pay? Is it not a fundamental human right? Why do millions in developing countries, in the slums of US cities or prisons in Russia, die prematurely of infectious diseases to which medical research has found successful treatments? Can we morally accept that medical research prioritizes cures for baldness or impotence over medicines that protect from drug-resistant tuberculosis or malaria? And, where has medical ethics come to that condones, or even supports, the "commodification" of medicine? How can cost-effectiveness and the ability to pay apply to essential medical treatment? he queries.

Rooted in his deep belief in human dignity and the fundamental nature of human rights, Farmer also draws strength from liberation theology as he "walks the talk". For more than 20 years, Farmer, anthropologist as well as medical doctor, has dedicated his life to the struggle of the "nobodies" for survival, health and dignity. Working among the poorest and the outcasts, he has lived with the evidence that illness is intimately linked with poverty. From his base in central Haiti, one of the world's poorest regions, he has embarked on an international crusade for social and economic rights and the right to health for all - and "that means every body!" Whether in Haiti, the slums of New York and Boston, in Peru or the prisons in Russia, "structural violence" has been the underlying cause for the desperate spiral of illness and destitution. Farmer uses the concept of "structural violence" broadly to describe social inequalities, lack of economic opportunities, activities of oppressive states: the "misery of extreme poverty". Nobel Prize winning economist Amartya Sen, one of Farmer's mentors, describes it as the destructive forces of "unfreedoms".

Farmer's book is a passionate testament to his many patients and their struggle for rights and dignity. Consequently, it is a damning critique of current health delivery services by governments, international health experts and aid agencies. He analyses the flaws of the charity and development models to healthcare and concludes that "...In a world riven by inequity, medicine could be viewed as social justice work."
While his recounting of individual cases makes at times gloomy reading, his empathy and fervour speak directly to us, his readers. We are drawn emotionally and intellectually into this complex and multifaceted challenge. Drawing on numerous scholars and practitioners, he exemplifies why we should question the underlying fabric of our current approach to human rights, development policy and globalized economy. Human rights work, he argues, has primarily been viewed from a legal perspective with an emphasis on civil and political rights. Instead, he insists, the focus needs to shift so that public health and access to medical care are treated as social and economic rights. These, in turn, have to be understood as critical as civil and political rights, he concludes.

PATHOLOGIES OF POWER is central to the current debates on health, social justice and human rights. It is also an essential tool for anybody involved in any aspect of public health care, medical ethics and sustainable development. Furthermore, it is an extraordinary study resource for everybody interested in the future of human well being. Farmer's own testimony, "bearing witness", and his in-depth analyses are enriched by detailed quotes and ample footnotes from a wide spectrum of analysts and visionaries. [Friederike Knabe, Ottawa Canada]

Dr. Farmer argues that, at the very least, access to health care should be a basic human right, especially if we are to uphold the belief that all human lives are equally valuable. Pathologies of Power is an indictment on the social structures that exist to keep the destitute poor of the world just as they are - destitute, impoverished, and without hope. While the powers-that-be make excuses, Dr. Farmer provides solutions that are, indeed, quite simple. His passion for his struggle to provide health care to the poorest of the poor is matched only by his disdain for the social inequities that perpetuate the structural violence inflicted upon the least fortunate of the world. It is heartening to know that there are a few compassionates, amongst the millions of complacent, that work so tirelessly to effect change that is so desperately needed. Hopefully this book will serve as a wake-up call for the rest of us.

This is a foundation book, if you have the time, money, and willingness to read broadly. If you want only one book on the cycle of health, human rights, poverty, and violence, buy Jeffrey Sachs' book on The End of Poverty: Economic Possibilities for Our Time in which this author, Paul Farmer, is praised, recognized, and clearly valued as a pioneer.

There are two bottom lines in this book:

1) Providing adequate low-cost health care for every human is the non-negotiable first step in eliminating human rights violations writ large (e.g. a year in a Russian prison could be an automatic death sentence from tuberculosis), poverty, and violence among the poor and between the poor and the more affluent.

2) Governments are failing. Here the author is in harmony with Philip Alcott, whose book The Health of Nations: Society and Law beyond the State calls for the over-turning of the Treaty of Westphalia (no more respect for the sovereignty of dictators--as in America, when government become too destructive, the People have the right to abolish the government). The author believes that a larger non-governmental network, and public pressure to force governments to apply more money to health and less money to the military killing machine, will in fact not only end poverty, but unleash sustainable indigenous wealth.

His case studies are of necessity somewhat tedious and can be skimmed if one's mindset is inherently in agreement with his propositions--they do however provide deep documentation for the skeptical.

Another book that might be substituted for this one (especially if buying and reading Sachs) is the pioneering work of Laurie Garrett, Betrayal of Trust: The Collapse of Global Public Health which documents the global collapse of public health. A very long book, my Amazon review of it is summative and may suffice.

Dr. Farmer also makes the rather helpful point that doctors doing good can go places where human rights inspectors would be considered intrusive. He praises Cuba, and rightly so. Any country that can put 10,000 medical practitioners into Venezuela, and thereby earn "first call" on Venezuelan oil, is operating at a strategic level of insight that the USA simply does not match today. Readers may not like hearing that the USA is slipping down into the middle ranks of "has been" nations, but that is the reality. On our present course, we are importing poverty, allowing pandemic disease to rear its ugly head through bird flu, mad cow disease and other mutations that will jump to humans, and we have also busted the national piggy bank with the double deficits (trade and debt).

When Dr. Farmer talks about the pathologies of power, he reminds me of Norman Cousin's book by the same title, but does so in a very practical personal way. If human beings are a primary source of national power, then having uneducated human beings subject to disease, poverty, crime, and terror has got to be the single dumbest thing any great power can allow to happen, at home or abroad. Lest anyone dispute my contention on this point, see my reviews of Barbara Ehrenreich, Nickel and Dimed: On (Not) Getting By in America and also David Shipler's The Working Poor: Invisible in America and Off the Books: The Underground Economy of the Urban Poor See my review of Sachs for more detail on the specific topic of global poverty and why it matters to every citizen.

All ten of the high-level threats to humanity are connected, and all twelve of the stabilizing policies from Agriculture to Water must be connected as well.

Paul Farmer has long been famous, I take it, within the medical community as a brave lifesaver in some of the world's most destitute places. He's lived in Haiti for 20-some years, tending to the poor and sick. He used his success against tuberculosis there as a springboard into Russia, where he's helped prevent the spread of Multidrug-Resistant Tuberculosis (MDRTB) within and beyond the country's prison population. He is, to put it succinctly, a saint.

His fame spread to a much broader audience with the publication of Tracy Kidder's Mountains Beyond Mountains: Healing the World: The Quest of Dr. Paul Farmer. Mountains Beyond Mountains is a hopeful, awe-inspiring, life-changing book. A couple years after reading it, I picked up Farmer's own Pathologies of Power, expecting great things.

It shouldn't be surprising that Farmer is a true Christian. Reading a lot of economics -- and even a lot of politics inspired by economics -- and then reading Farmer, I'm struck by how arid the former sounds in contrast to the latter. A cold calculus might explain to us why we should treat the poor well. Maybe we can justify redistribution to the poor because their utility from one marginal dollar is higher than that for a wealthy person. Or maybe we should aim to stop MDRTB in prisons because those prisoners will go out into the outside world and infect the nonpoor. Farmer cuts through that: *we should help the poor because they are poor, and it is our obligation as humans to serve the least fortunate*.

Not only that: we should help them because, in most every case, their poverty is a sign that we have failed them. Farmer angrily ticks off case after case, most of them straight from his first-hand experience, where what initially looks like a senseless, random death is seen to be a symptom of a deeper systemic problem. The most haunting of these may be the death of a young Haitian girl named Acephie who contracted HIV from a Haitian soldier. She had sex with him because soldiers are some of the few Haitians with dependable salaries. But what led Acephie into that position of economic dependence to begin with? It didn't help that the Haitian government, with the blessing of Western development agencies, had evicted Acephie's family years before to build a dam; the family had to move to higher, poorer ground because of someone's idea of what was good for them. The road from there leads more or less directly to the AIDS death of a Haitian girl. (James Scott's Seeing Like A State contains a lot more tragedies in this direction.)

Pathologies of Power is filled with stories like that. It is not a hopeful book; it is very, very bitter. This despite Kidder's blurb on the cover to the contrary: Kidder recognized the anger, but saw hopefulness that I didn't.

We won't permanently end the suffering of the poor, says Farmer, until we fix the causes of that suffering. He labels these causes "structural violence." Structural violence is what leads poor Haitians to die of preventable disease ("stupid deaths," to use the Haitians' phrase) because the World Health Organization deems their treatment "cost-ineffective," while pharmaceutical companies get wealthy and we argue over the cost-effectiveness of keeping old Americans alive longer. A world devoted to lifting up the least fortunate would stop the stupid deaths first. Drug companies and governments would help the poor *even if there were no money to be made from them*.

Based purely on its message, I couldn't recommend this book highly enough: everyone should learn to think like a true Christian in the midst of rapacious capitalism. But stylistically it's a chore; Farmer is angry, and is lashing out in all directions. His anger leads him to repeat himself 20 or 30 times throughout the book, and to offer very few actual solutions. Which is surprising: the man himself lives to solve the problems of the destitute.

So I think it's vital to differentiate Farmer The Man from Farmer The Author. That's also why I'd recommend that you go right out and read Mountains Beyond Mountains instead: it teaches the same powerful lessons, only a lot more concisely and inspiringly.

Dr. Farmer's investigation is a powerful explanation of how the structure of society and power distribution decides who succeeds, fails, gets sick, and stays healthy. His book not only reveals the ugly roots of how inequality is sustained and is oppressive, but by doing so, also outlines the principles for a humane way forward.

Farmer is both an MD and anthropologist, and his writings of disease and the poor (topics unfortunately remote to most westerners) are very personal and interesting. He is a hands-on care giver in Haiti and also a powerful influence in the world politics of third world medical care. Please read this book.

Paul Farmer is a Harvard MD and PhD (anthropology), clinician, tuberculosis specialist, author of numerous books and scholarly articles, recipient of a MacArthur "genius" grant, and Professor of Medical Anthropology at Harvard Medical School--when he is not living in a hut in his beloved Haiti where he founded Partners in Health, or traveling a quarter million miles a year to lecture, visit prisons, or meet with George Soros or the Gates Foundation. Most important of all, Farmer is an unapologetic, outspoken, and radical advocate for the poorest of the poor. Adequate health care, he insists, is a basic human right for every human being, and our world is failing miserably in this regard. His fascinating life story is told by Pulitzer Prize winner Tracy Kidder in the book Mountains Beyond Mountains (2003).

According to a World Bank study from 1993, today in Sub-Saharan Africa "the median age at death is less than five years," (p. xi; no typographical error). Such deplorable disparities between rich and poor, Farmer writes, are not random occurrences, they are not accidental, inescapable or necessary. Rather, they result from pathologies of power, human agency, and structural violence. Quoting the liberation theologian Jon Sobrino, "The poor of the world are not the causal products of human history. No, poverty results from the actions of other human beings" (p. 143). Which is to say that the brutal asymmetry that consigns over half the world to wretchedness is not irremediable. Resignation, in fact, is the most inexcusable choice we could make. However daunting and complex, we can ameliorate these unacceptable conditions if we make other choices: "This book is a physician-anthropologist's effort to reveal the ways in which the most basic right--the right to survive--is trampled in an age of great affluence, and it argues that the matter should be considered the most pressing one of our times" (p. 6).

Farmer spends considerable time charting anecdotal evidence from his two decades of clinical practice serving the poorest of the poor. These detailed case studies from Haiti, Chiapas, Peru, Russia and Cuba are not mere examples but instead emblematic of the problem. Further, following liberation theologians who have deeply influenced him, Farmer strongly advocates listening carefully to the voices of the poor themselves, in their own words, and not only to health "experts" in Geneva, New York and Paris. "I believe," writes Farmer, that 'the poor and impoverished of the world, in virtue of their very reality, constitute the most radical question of the truth of this world, as well as the most correct response to this question'" (p. 202).

Some will dismiss rhetoric like that as from a wild-eyed idealist, or an angry extremist, but Farmer would respond that what is extreme and harsh are the conditions of way too many human beings in the world, which ought to evoke anger, and not his passionate advocacy for them (p. 254). Rather than merely "manage" these horrible social inequalities, Farmer challenges each one of us to make a difference by what he calls "pragmatic solidarity" with the poor.

In Pathologies of Power Dr. Farmer has provided critical evidence of health care as it is effected by social and global inequalities. He discusses cases regarding AIDS and the Haitian Boat Refugees, structural violence in Haiti and Mexico, multi-drug resistant TB in Russia, community based health projects in Chiapas, amongst other reflections on relevant cases and history. The book makes a forceful argument for the need to integrate health and human rights to improve the livelihoods of marginalized people. Professor Farmer recommends the following to complement present efforts to achieve the new health and human rights agenda: make health and healing the symbolic core of the agenda, make provision of services central to the agenda, establish new research agendas, achieve independence from powerful governments and bureaucracies, assume a broader educational mandate, and secure more resources for health and human rights. Furthermore, Dr. Farmer has provided evidence showing that the implementation of the said recommendations saved lives, improved healthcare outcomes, and positively impacted the lives of the sick and marginalized.

I greatly respect Dr. Farmer's work and have followed Partners In Health's efforts in Haiti over the last several years. While this book has substantive significance in its attempts to discuss several public health and human rights crises in their social, economic, and political contexts; I think it fails to make a cohesive point or tell a cohesive story in the way that a book (rather than a collection of essays) demands. As a public health and human rights worker, I understand where Farmer was trying to go with his writing but I don't think he actually gets there in a coherent way. Perhaps he should have focused only on one health issue or country in order to more fully flesh out his thesis.

I do recommend this book as well as a visit to the Partners in Health web site at www.pih.org.