AFRO-NETS> Book Review: Pathologies of Power

[Claudio Schuftan <aviva@netnam.vn>]

Book Review: Pathologies of Power
---------------------------------
Health, human rights, and the new war on the poor
 
Paul Farmer, with a foreword by Amartya Sen
University of California Press, Berkeley and Los Angeles, 2003 
402 pp. U$ 27.50
 
 
Although Dr Paul Farmer's latest book does not really talk about 
a 'new' war on the poor, but rather an ancient one, the author 
has the full moral authority to write this book. In vivid case 
studies from both the North and the South, Farmer shares with us 
his experiences with the violation of human rights. The case 
studies may be depressive, but overall, they convey a message of 
optimism. The book not only searches for, analyzes and explains 
the social causes of structural violence and extreme suffering, 
but it also explores and deplores our collective tolerance of the 
social aberrations and abuses it describes. The book centers 
around a well documented critique of the liberal views on human 
rights, which have rarely served the interests of the poor.
 
Farmer advances many and varied loosely-bound theses among which 
the following I think are worth sharing:
 
On Power: The asymmetry of power generates many forms of quiet 
brutality. It is inequities of power that prevent the poor from 
accessing the opportunities they need to move out of poverty. So, 
the 'pathologies of power' take their toll --including a toll in 
human lives. Denying this only serves the interests of the power-
ful; a change of mentality is needed in the hearts and minds of 
those with power. Structures and not just individuals must be 
changed if the world is to change.
 
On Inequity: It is social and economic inequalities that deny 
services to the poor. The promotion of equity is the central in-
gredient for respecting human rights in health; this, at a time 
when the prevailing dogma calls for projects to be 'self-
sustaining' and 'cost-effective'. Cost-effectiveness may be rele-
vant, but does not reduce inequity.
 
On the poor: The poor are not the casual victims of human his-
tory; poverty results from the actions of other human beings, the 
result of man-made structural violations. For instance, the ma-
jority of ethnic minorities are poor; in the literature, their 
race is used as a substitute for class, but their plight is the 
result of the ongoing process of oppression. The poor are not 
begging, they are demanding a right they have earned.
 
On Poverty: Poverty, part and parcel of the global free-market 
system, is the world's greatest killer. It is not enough to im-
prove the situation of the poor within the existing social rela-
tionships. The poverty of the poor demands that we build a dif-
ferent, more just social order.
 
On Public Health: The right to health is perhaps the least con-
tested social right --and yet the poor bear the brunt of both 
preventable ill-health and human rights violations. Health advo-
cacy has failed miserably. Somehow, public health must be linked 
to a return to social justice. With no access to treatment, pneu-
monia or TB is more lethal than AIDS; the discoveries of Salk, 
Sabin and even Pasteur remain irrelevant to much of humanity. 
Poverty puts people at risk, but bars them from access to effec-
tive treatment. Denial of care to those who do not pay is legiti-
mized in the free market system. We are at a cross-road: Health 
care can be a commodity to be sold or it can be considered a ba-
sic social right; it cannot be both. Ergo, equity also is the 
central challenge for the future of public health. The author 
even speaks of the 'pathogenic role of inequity' (!) and hence of 
a 'right to equity'.
 
On Ethics: Relaxed ethical practices are unacceptable, we know. 
But, without a social justice component, medical ethics risks be-
coming yet another strategy for managing inequality. Conventional 
medical ethics are concerned with the ethics of the individual; 
it is quite divorced from the tangible social reality. Social and 
economic rights are at the heart of what must become the new 
medical ethics; we need an ethics of distributive justice.
 
On Solutions Attempted: It is totally unacceptable to attempt a 
differential valuation of human life. Only by including social 
and economic rights in the struggle for human rights, can we pro-
tect those most likely to suffer the insults of structural vio-
lence. This is part and parcel of offering a more viable direc-
tion for future action. But ultimately, the real energy to find 
workable solutions can only come from the oppressed themselves.
 
At the end of the book, Farmer makes six suggestions; they are:
 
1. To make health and healing the symbolic core of the agenda: He 
calls for engaging health professionals in human rights work so 
as to ensure health for all and to decrease health inequalities.
 
2. To make the provision of services central to the agenda: He 
asks us to listen to the abused when providing services; to dis-
tribute interventions equitably; to closely work with community-
based organizations to improve access. He reminds us that States 
are best placed to protect the basic rights of poor people; that 
State failure cannot be rectified by human rights activism by 
NGOs; that the search for (economic) sustainability is often at 
odds with social justice approaches to health; that efficiency 
cannot trump equity in the field of health and human rights.
 
3. To establish new research agendas: He thinks we need to exam-
ine why some populations are at risk and others are spared human 
rights violations. Farmer fittingly reminds us, however, that re-
search should remain secondary and be designed to improve ser-
vices and social justice.
 
4. To assume a broader educational mandate: Do not preach only to 
the converted, he tells us; also, do not try to teach lessons to 
recalcitrant governments and reluctant international agencies; 
simply more education will not do for them.
 
5. To achieve independence from powerful governments and bureauc-
racies: A central irony of human rights law, he reminds us, is 
that it consists largely of appeals to the perpetrators; collabo-
ration with communities in resisting ongoing violations of human 
rights is the way to go. And finally,
 
6. To secure more resources for health and human rights: States 
have become less able to help their citizens attain social and 
economic rights even though they have most often retained their 
ability to violate these rights. It is easy to demand more re-
sources, what is hard is to produce them.
 
 
 
I do want to imagine a world where Farmer's six suggestions are 
applied, but in it, I fail to see the human rights problems he so 
aptly describes resolved. Moreover, I do have a few other points 
in which I disagree with the author:
 
Although he complains that human rights discussions have been ex-
cessively legal and theoretical, I think this was needed to bring 
human rights to the place it now has. He claims that the current 
human rights discourse is at times divorced from reality. But no 
longer: UNICEF and CARE, to name just two organizations, are now 
heavily involved in Human Rights and Capacity Analysis work in 
progressively practical ways (see below). So the paradigm is no 
longer using human rights as a language of moral imperialism, as 
he claims.
 
Farmer, an adept of liberation theology, emphasizes suffering 
perhaps more than injustice (the latter, as a Marxist would do). 
I think it is not about loving the poor when struggling for their 
liberation, but rather to solidarize with them in their struggle. 
To act as a physician 'in the service of the poor' is not what I 
think it to be all about. But 'pragmatic solidarity' and a 'com-
mon cause with those in need' are also invoked by the book. The 
text is, therefore, not free of contradictions.
 
Farmer fails to mention the growing human rights movement that is 
speaking of claim holders and duty bearers and of Capacity Analy-
sis and the holding accountable of duty bearers. His liberation 
theology embodies a political analysis, namely seeking the root 
causes, eliciting the views of the abused and incorporating these 
views into all actions. Farmer and liberation theology propo-
nents, for example, also see introducing antiretroviral therapy 
to the AIDS afflicted, no matter where and how many they are, as 
fitting (even if not sustainable or replicable). I do have prob-
lems with that.
 
Although Farmer says that his ideas do not demand loyalty to any 
specific ideology, the full scope of his theses in the book bla-
tantly deny this stance. I ask myself, where is the shame in 
openly declaring that one has an anti-neoliberal ideology? In the 
end, to Dr Farmer, the health angle of human rights proves more 
pragmatic than approaching the problem as one related to the need 
for drastic reforms in the patterns of justice of a country. I do 
not see it as a matter of pragmatism; in human rights work we are 
called to work on all fronts simultaneously.
 
Although channeling resources to the destitute wherever they are 
may be the 'right thing' and the 'human rights thing' to do, this 
is by far not enough. Better sooner than later, we have to embark 
on a process that roots out the structural problems underlying 
widespread human rights violations (e.g., gross maldistribution 
of wealth). The real underlying war cannot remain undeclared (his 
words). Progress will ultimately be more plausibly judged by the 
reduction of deprivation than by the further enrichment of the 
opulent (Amartya Sen). In Dr Farmer's words: we simply cannot 
feel too old and tired for justice.
 
The author concedes his book is principled, but extreme. It is 
not harsh though; the realities it describes are; the crimes it 
unveils are predictable and ongoing. What all the victims have in 
common and share is poverty and an unwillingness to knuckle un-
der. Pathologies of power damage everybody, but kill chiefly the 
poor. We cannot, therefore, stay in our comfort and innocence.
 
In sum, the book is a source of innumerable pearls of wisdom, but 
the same are often buried in longish paragraphs or long though 
relevant quotes. The book also perhaps comes back too much on the 
same issues in its different chapters, only doing so from 
slightly different angles. I found Chapter 5 on Health, Healing 
and Social Justice heavy to read.
 
In closing, Farmer tells us that if we lack the ambition to do 
what is needed, we should expect the next 50 years to yield a 
harvest of shame. In the Afterword, Dr Farmer asks why we should 
give a damn? And the 'because' is loud and clear: It is not use-
less to complain! You've got to read the book to see if you 
agree.
 
Claudio Schuftan MD
Ho Chi Minh City, Vietnam
mailto:aviva@netnam.vn 

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