PHA-Exchange> book review

[Claudio]

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[db1] '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 powerful; 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 ingredient 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 relevant, but does not reduce inequity.

 

On the poor: The poor are not the casual victims of human history; poverty results from the actions of other human beings, the result of man-made structural violations. For instance, the majority 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 improve the situation of the poor within the existing social relationships. The poverty of the poor demands that we build a different, more just social order. 

 

On Public Health: The right to health is perhaps the least contested social right --and yet the poor bear the brunt of both preventable ill-health and human rights violations. Health advocacy has failed miserably. Somehow, public health must be linked to a return to social justice. With no access to treatment, pneumonia 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 effective treatment. Denial of care to those who do not pay is legitimized 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 basic 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 becoming 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 protect those most likely to suffer the insults of structural violence. This is part and parcel of offering a more viable direction 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 distribute 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 examine why some populations are at risk and others are spared human rights violations. Farmer fittingly reminds us, however, that research should remain secondary and be designed to improve services 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 bureaucracies: A central irony of human rights law, he reminds us, is that it consists largely of appeals to the perpetrators; collaboration 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 resources, 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 excessively 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 'common 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 Analysis 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 proponents, 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 problems 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 blatantly 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 under. 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 useless to complain! You've got to read the book to see if you agree.

 

Claudio Schuftan MD, Ho Chi Minh City.

aviva at netnam.vn 



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