Paul Farmer is an internationally renowned physician and medical anthropologist at Harvard Medical School, attending physician in infectious diseases and Chief of the Division of Social Medicine and Health Inequalities at Boston’s Brigham and Women’s Hospital, and medical director of the Clinique Bon Sauveur in Haiti. He is also the founding director of Partners in Health (PIH), which since its establishment in 1987 has formed partner projects with community organizations in seven different countries including Russia, the United States, and Mexico to provide modern health care services for the economically disadvantaged. PIH focuses its efforts on combating the spread of tuberculosis and HIV-AIDS among some of the world’s most vulnerable populations. Author of more than 200 articles and books, Farmer has received a MacArthur Foundation “genius” award and is the subject of Pulitzer Prize-winning author Tracy Kidder’s Mountain Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World (2004). Amartya Sen, Nobel laureate in economics, wrote the foreword to Pathologies of Power, and calls Farmer a “visionary analyst” (P. xii).
Farmer’s book is divided into two parts, the first called “Bearing Witness,” the second “One Physician’s Perspective on Human Rights.” He draws upon his experiences with patients in Haiti, Chiapas, Boston, and Russian prisons to argue that whereas suffering is admittedly a universal constant the extent to which these poor, disenfranchised, or subject populations suffer is both unnecessary and the result of “structural violence.” Part One illustrates the relationship between suffering and structural violence through portraits of such people as Acйphie, a young Haitian woman who died from AIDS as a result of her economically-necessitated liaison with a military captain; Sergei, a young man arrested for forgery soon after the break-up of the Soviet Union who contracted TB during his long pre-trial detention in Kemerovo’s overcrowded prison; and Tzeltal-speaking residents of the Chiapan village of Moisйs Gandhi who cast their lot with the Zapatistas in an effort to preserve their human dignity. Part Two is intended to analyze these cases while pressing the case that modern healthcare service is a human right. Farmer’s ethical basis for this view stems from “liberation theology,” which has been fundamental to many Latin American social reform movements over the past several decades. In actuality, each part of Pathologies of Power consists of a mix of anecdote and analysis: many individuals introduced early reappear later; and much of the analysis consigned to the second part is foreshadowed in the first. Taken as a whole, then, this book may be said to be both admirable and frustrating by turns. Admirable is the passion with which Farmer writes. He acknowledges from the beginning that he is no objective scholar: he is not distant from his topic nor does he claim to be without an agenda. On the contrary, he advocates without reserve that the poor people he argues are being victimized by globalization have the right to benefit from modern advances in medicine, and criticizes both fellow physicians and anthropologists for their scholarly and cerebral detachment from their subjects by suggesting, among other things, that practicing such professions without the accompaniment of praxis is itself a form of structural violence. Such forthrightness results in a narrative which at its best is a compelling read.
Farmer unapologetically challenges the moral relativism he several times associates with post-modernism, stating in no uncertain terms that it is wrong for so many to suffer when there is such an abundance of worldwide wealth. The unequal distribution of this wealth is in Farmer’s view the pathology that supersedes all others. Another example of pathology is the United States governments’ policies towards Haiti which during the Duvalier regime functioned at the expense of democracy and human rights, and during Aristide’s government thwarted the disbursement of loans to fight AIDS and other chronic diseases. A similar pathology leads health experts to classify as “untreatable” multi-drug resistant tuberculosis (MDRTB) among Russia’s prison population because treating it is supposedly not cost-effective, despite programs in Peru and elsewhere that prove them wrong. What is truly not cost-effective is not to treat MDRTB, because the release of stricken prisoners into the general population in Russia or anywhere else promises an epidemic that will indeed be beyond many government’s fiscal means to combat. Farmer’s portrayal of pathologies leading to structural violence is most effective in his comparison of the treatment during the 1990s of HIV-infected Haitian refugees at Guantanamo with that of patients in a Cuban AIDS facility. After describing conditions in the barbed wire-ringed Camp Bulkeley that, in hindsight, eerily presaged the treatment of Al Queda suspects, he documents how The New York Times and other mainstream media covered up the criminal violations of human rights there but ignored the success of what was called a prison camp in Cuba.
Farmer’s book is also frustrating, however, given the extent to which he allows his passion to lead to diatribes that lack clear explanations of the power relations he associates with various structural violence. Having seen with his own eyes people shot and killed and dying agonizing deaths from curable diseases, Farmer has every right to be mad as hell over the injustices he describes; but one wishes that what he acknowledges is “a plaintive book” (P. 255) were not so consistently plaintive but rather more attuned to socio-political realities, for all too often an ill-defined mega-system gets blamed without consideration of its intricacies. His fine elucidation of pathologies associated, for example, with the Guantanamo affair is lacking in his explanation for why Russia’s prisoners needlessly contract and suffer MDRTB. The assertion that Washington’s support for perestroika is primarily to blame for the collapse of Russia’s medical infrastructure is inadequate, and not only fails to account for pathologies endemic in the Kremlin’s regard for prisoners but sounds unfortunately like a conspiracy theory. This is an instance where honing more closely to dispassionate analysis rather than (as is done throughout) identifying the United States as the prime culprit would have produced a more accurate diagnosis. Similarly, it is mentioned three times that the Zapatistas began their uprising the day NAFTA was signed; yet there is almost no information here about the internal Mexican politics that preceded their rebellion.
Most problematic is the call for a re-distribution of wealth based on the assumption that globalization has made the world’s rich richer and the poor poorer. As Jeffrey Sachs has noted in another review, this claim sits uncomfortably beside dramatic increases in average living standards in China and other large countries during the past several decades. Regardless of one’s view of globalization, to suggest that it has increased worldwide poverty is misleading. Farmer similarly castigates the United States and other states for replacing foreign aid with business investment strategies after the Cold War, but refuses to analyze the political and economic motivations behind this transition, instead preferring to frame it as resulting from moral failure. Yet even if one grants that there is an ethical lapse here, he provides no explanation for why this lapse is occurring now and in this way. Finally, the call for a redistribution of wealth avoids the thorny problem of constructing mechanisms that would be needed to essentially compel haves (whether individuals or states) to give more to have-nots. Farmer often seems to forget that the countries he most criticizes possess what countries with down-trodden populations tend to lack: pluralistic democracy. American voters rarely support large increases in foreign aid (especially so after Iraq and New Orleans); and philanthropists George Soros and, lately, Bill Gates are exceptions to the rule governing what billionaires do with their money.
Farmer glosses over these and other dismal realities with an inspiring paean to the new theodicy (a word several times invoked) he associates with “liberation theology.” “Liberation theology” is problematic for several reasons, not least of which is its association with utopian schemes that historically either failed their advocates or are failed by them. Despite having emerged from the Second Vatican Council (1962–1965), it has been denounced by both John Paul II and Benedict XVI and is often compared to Communism. Whether or not this means anything to those who subscribe to its tenets is beside the point, for it is the existence of competing ideologies that presents the most serious barrier to effectuating the belief expressed most notably in the United Nation’s “Universal Declaration of Human Rights,” that health care is a right for all, regardless of economic status. In the end, to establish the connections needed to effectuate these and other human rights, contrary ideologies and their origins need to be critically assessed and understood rather than simply presented as ethical lapses. This book succeeds best by demonstrating what should be the real motivation behind such an endeavor.