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

From the New England Journal of Medicine, February 12, 2004
There are many kinds of gifted physicians: clinicians, researchers, and those who build institutions. Paul Farmer is the rarest of all: a prophet. Pathologies of Power is a jeremiad on how the "structural violence" of denied opportunities, economic deprivation, violent despots (and the powers supporting them), and international financial organizations harm the health of billions of people who are so distant that they are glibly and uncomprehendingly referred to as living in a "third world." This summary does not do justice to the richness of the book. Farmer deftly weaves personal stories from his work with the dispossessed, careful academic notes, and well-chosen quotations from intellectuals, poets, and proponents of liberation theology. These citations introduce marvelous writers who are not well known to readers from the United States. Farmer builds from the 19th century's Rudolph Virchow, who argued that physicians must advance public health through political and social reform as "attorneys for the poor." Farmer's anecdotes about mobilizing the poor on their own behalf echo the work of Norman Bethune. And Farmer extends Jonathan Mann's fusion of human rights and medical ethics to health and human rights. Farmer, a physician and an anthropologist, offers a blistering critique of anthropologists who describe colorful folkways or bits of social problems, such as sexual barter, without illuminating how such practices are sustained by class and political history. This critique and Farmer's advocacy for oppressed persons mark this book as a prophetic work. Therefore, it is also a towering work of medical ethics. Farmer's critique of anthropology applies equally well to medical ethics, with its scholastic focus on moral curiosities and its decorous silence on "political" issues such as the lack of insurance or the ways in which the policies of international financial organizations affect health and health care for the world's poor. The prophetic voice speaks for the marginalized and can strike listeners as shrill, odd, or discomforting. Farmer skirts that risk by careful scholarship and compelling writing. That being said, I think he overrates the competence of Haiti's reelected president Jean-Bertrand Aristide and the success of Cuba's program to suppress the human immunodeficiency virus. Though he correctly notes the entrenched and mistaken pessimism of the international health authorities about the ability of dispossessed people to complete tuberculosis treatment, he overestimates the capacity of the available infrastructure in many poor countries to manage daily antiretroviral therapy. Such quibbles do not diminish the importance of his larger thesis. Farmer calls on physicians to mount a sustained engagement against human-rights abuses as the roots of disease, disability, and lack of access to health care. Health itself, rather than technical compliance with laws or accords, must be the standard for evaluating governments, foreign policy, and the national restructuring plans of such organizations as the International Monetary Fund. Expanding health services and democratizing information must be central to the global agenda of all physicians. Academic research and education must use the privilege conferred by their power and independence to articulate specific relationships between human rights and abuses of human rights with health and disease. We live in a time when epidemics keep pace with globalization and when the map of deprivation and human-rights abuses precisely overlays the atlas of war, disease, and terrorism. Farmer's sane prescription is more likely to work than is rationalizing neglect, dribbling charity, averting our eyes, or attempting to build a garrison state bounded by a cordon sanitaire. Pathologies of Power is a profound work; it deserves the widest possible audience. Steven Miles, M.D.Copyright © 2004 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.


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Pathologies of Power uses harrowing stories of life and death to argue that the promotion of social and economic rights of the poor is the most important human rights struggle of our times.


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