Pathologies of Power: Health, Human Rights, and the New War on the Poor [Anglais] [Relié]

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]

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.