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Pathologies of Power: Health, Human Rights and the New War on the Poor (California Series in Public Anthropology) Hardcover – 9 May 2003
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"It's crucial that we confront the link Farmer reveals between social inequality and disease."--"Utne"
From the Inside Flap
"This is an angry and a hopeful book, and, like everything Dr. Farmer has written, it has both passion and authority. Pathologies of Power is an eloquent plea for a working definition of human rights that would not neglect the most basic rights of all: food, shelter and health. This plea has special potency because it comes from Dr. Farmer, a person who has proven that the dream of universal and comprehensive human rights is possible, and who has brought food, shelter, health, and hope to some of the poorest people on this earth."--Tracy Kidder, author of The Soul of a New Machine and Home Town
"Farmer's brilliance and charisma leap from the pages of his book. He challenges us to face the urgent theoretical and political challenges of the twenty-first century by linking structural violence to embodied social suffering and in the process calls for a new definition of human rights. Once this book is out, we will no longer be able to remain complacently--or rather, complicitly--on the sidelines."--Philippe Bourgois, author of In Search of Respect: Selling Crack in El Barrio
"A passionate critique of conventional biomedical ethics by one of the world's leading physician-anthropologists and public intellectuals. Farmer's on-the-ground analysis of the relentless march of the AIDS epidemic and multi-drug resistant tuberculosis among the imprisoned and the sick-poor of the world illuminates the pathologies of a world economy that has lost its soul."--Nancy Scheper-Hughes, author of Death without Weeping: the Violence of Everyday Life in Brazil
"In his compelling book, Farmer captures the central dilemma of our times--the increasing disparities of health and well-being within and among societies. While all member countries of the United Nations denounce the gross violations of human rights perpetrated by those who torture, murder, or imprison without due process, the insidious violations of human rights due to structural violence involving the denial of economic opportunity, decent housing, or access to health care and education are commonly ignored. Pathologies of Power makes a powerful case that our very humanity is threatened by our collective failure to end these abuses."--Robert S. Lawrence, President of Physicians for Human Rights and Edyth Schoenrich Professor of Preventive Medicine at the Bloomberg School of Public Health, Johns Hopkins University
"Farmer has given us that most rare of books: one that opens both our minds and hearts. It stands as a model of engaged scholarship and an urgent call for social scientists to forsake their cushy disregard for human rights at home and abroad."--Loic Wacquant, author of Prisons of Poverty
"Paul Farmer is an original: a powerful writer, an insightful theorist, and a human rights activist on behalf of the health needs of some of the poorest and most excluded people on the planet. Pathologies of Power brings together all his strengths, as a thinker and an activist. Every health worker, human rights teacher, and government official who seeks to improve the health status and life chances of their fellow human beings simply must read this book."--Michael Ignatieff, author of Human Rights as Politics and Idolatry
"Paul Farmer is a great doctor with massive experience working against the hardest of diseases in the most adverse circumstances, and, at the same time, he is a proficient and insightful anthropologist. Farmer's knowledge of maladies such as AIDS and drug-resistant tuberculosis, which he fights on behalf of his indigent patients, is hard to match. But what is particularly relevant in appreciating the contribution of this powerful book is that Farmer is a visionary analyst who looks beyond the details of fragmentary explanations to seek an integrated understanding of a complex reality."--Amartya Sen, Nobel Laureate, Economics
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Farmer's basic aim in this book is to argue for a working definition of Human Rights that includes those social justice: in general those social and economic rights which articles 22-27 of the UN Declarations of Human Rights (1948) describe. His particular expertise is in the medical sphere and it is that aspect that the book primarily, but far from solely, focuses on. The first part of the book is based around his experiences with the Non-Governmental Organisation "Partnerships in Health" (which he co-founded in 1987) in Haiti, Cuba, Mexico (Chiapas) and Russia. Haiti is where Partnerships in Health started its first Clinic in an area of Central Highlands where a World Bank funded Dam had submerged the best farming land driving the peasants onto higher, far less fertile land, where they struggle to live off the land, and their community fragments with individuals losing hope and not infrequently ending up in the slums of Port-au-Prince. In Cuba Farmer compares the treatment of HIV+ Haitian refugees at the US base in Guantanamo Bay (after the coup of 1991) and the Cuban's own record with their own HIV+ nationals at Santiago de las Vegas. The former is described as an "Oasis to Haitians" in the New York Times, the latter is generally pilloried in the press and subjected to criticism by Human Rights Groups. The reality Farmer unearths is a brutal, inhuman "quarantine" facility at Guantanamo, and a decent, caring open facility at Santiago de las Vegas. Reality is, not for the first time, the exact opposite of what the mainstream media would have us believe.
In Chiapas the focus is on the lives of the indigenous population and their Zapatista uprising which began in 1994. This was an effort by the poor marginalised Indians of the province in southern Mexico to free themselves of the "structural violence" and oppression of the Mexican state which by then had been a de facto one party state for decades. In Russia Farmer visits prisons, including those where prisoners with Tuberculosis are isolated, with completely inadequate treatment, looking to set up a partnership with the Russian Department of Justice in order to provide the best and most effective care for those who are being left to die in Russia's massive prison system (second in size per capita to that of the United States).
In the second part of the book entitled "One Physician's Perspective on Human Rights" Farmer reflects on the experiences he describes in the first part, including a definition of what he terms "structural violence" (in short, a form of violence where some social structure or social institution harms people by preventing them from meeting their basic needs) and an exploration of the ideas of Liberation Theology with its preference for looking out for the poor and impoverished. It's perhaps best to quote Paul Farmer at length to get the best idea of where he is coming from:
"In short, this "one physician's perspective on human rights" may be summed up as follows: just as the poor are more likely to fall sick and then be denied access to care, so too are they more likely to be the victims of human rights abuses, no matter how these are defined. By including social and economic rights in the struggle for human rights, we help to protect those most likely to suffer the insults of structural violence. It is my belief that the liberation theologians, in advocating preferential treatment for the poor, offer those concerned with human rights a moral compass for future action. A preferential option for the poor, and all perspectives rooted in it, also offers a way out of the impasse in which many of us caregivers now find ourselves: selling our wares and services only to those who can afford them, rather than making sure that they reach those who need them most. Allowing "market forces" to sculpt the outlines of modern medicine will mean that these unwelcome trends will continue until we are forced to conclude that even the practice of medicine can constitute a human rights abuse." (p138)
Subsequent to the publication of this book Farmer came a special envoy under ex-president Clinton (whom he criticises in relation to the his administration's policy towards Haiti and Haitians in the first part of the book) for Haiti. Hopefully his close proximity to established power, which I'm certain he's done for quite pragmatic reasons and laudable aims wont blunt Farmers deservedly caustic critique of the way in which the world's poor are treated, either medically or in more general terms. It certainly is difficult to believe that the author of this excellent book, finely written and offering a deep analysis and profound critique of the concept of Human Rights, as well as making a strong case for their definition to include Social and Economic Rights, would act other than for the poor.
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 their 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]
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Farmer draws on his extensive knowledge and fieldwork in Haiti in all the books I've read by him, so this one is no exception. That said, the book is still unique and not a repeat/rehash of prior work as is so very common.
I wish I could get more people to read books like this, which very logically point out that social Darwinism is bs, and power rules the world. This is a great critique and discussion of globalization, health, and human rights.
I wish we could convince our current administration to put this on their list of required readings...
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.
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