Summary and Critique of Paul Farmer’s Book:
Pathologies of Power
In Pathologies of Power, Dr. Paul Farmer, anthropologist and infectious diseases specialist, attempts to reframe the struggle for social and economic rights within the context of health and medicine, and offers some solutions to the growing inegalitarianism between the access to health and technology in rich and poor countries. In passionate and angry detail, Dr. Farmer draws from personal experiences treating the destitute in third world countries. His book covers an intersection of many different thought-communities, and avoids falling into academic speech in any one particular field. Farmer argues that the destitute are often silenced “from above” (Farmer, 48). For the sake of analysis this article will be organized into two main sections: summary and critique. While Dr. Farmer’s book brings to light the hypocritical nature of “structural violence,” and offers some excellent critiques of the current human rights system, he attaches too many of his solutions in liberation theology, rejects the notion of sustainability, and assigns educational research a predetermined directive.
Farmer offers a summary himself into the structuring of his book: 1) Firsthand “partial and dated,” experiences from working in third world countries and 2) restructuring of the human rights framework and critiquing the “liberal views on human rights” (Farmer, 19). In the first half of Farmer’s book we are exposed to the founding principles of the book, which Farmer uses in the second half to critique the current framework regarding health and human rights. Using Latin America (especially Haiti and Cuba) and Russia, Farmer introduces us to concepts using personal experiences. These experiences are very tragic, and Farmer seems to grapple with them ethically throughout the book, in the end acknowledging “I contemplate my own loss of innocence with resentful, sometimes even tearful, silence” (Farmer, 256). The first concept we are exposed to is “Structural Violence” (Farmer, 40). Farmer states, “the term is apt because such suffering is “structured” by historically given (and often economically driven) processes and forces that conspire…to restrain agency” (Farmer, 40). In other words, structural violence puts the blame of risk on the pathology of power, to “reintroduce the concept of structural violence and to link it to the acute violence of war crimes and systemic assaults against human rights” (Farmer, 20).
Farmer introduces us to what he calls the “pathologies of power” (Farmer, 40). This pathology (disease) reveals itself in many of Farmer’s stories, as the victim is subjugated at every turn, often fighting invisible forces, resulting in a painful death. “These afflictions are not the result of accident of a force majeure (legal term act of God); they are the consequence, direct or indirect, of human agency” (Farmer, 40). The disease of power is to blame Farmer would argue, as countries, international organizations, development programs, all operate under a similar pathology. Structural violence stems from the pathologies of power, so the two in Farmer’s opinion are intimately related. The responsible group for attaching structural violence within the pathology of power is liberation theologians.
Liberation theology, Farmer writes, “has always been about the struggle for social and economic rights” (Farmer, 141). Farmer argues that being poor is indeed a factor in increased risk of death: “Every careful survey, across boundaries of time and space, shows us that the poor are sicker than the non-poor” (Farmer, 140). Farmer accuses the rich world of simply managing this inequality. He insists that “evil is not only present in the hearts of powerful individuals who much things up for the rest of us but is embedded in the very structures of society” (Farmer, 143). Liberation theology attributes social freedom as the striking of this evil. Liberation theology finds “fault” with the entire notion of human rights as defined within liberal democracies (Farmer, 142). Liberation Theology has much to contribute to health as it relates to human rights, and Farmer argues, “this methodology has proven useful for promoting health in settings as diverse as Brazil, Guatemala, El Salvador, rural Mexico, and urban Peru” (Farmer, 140). As applies to medicine, liberation theology affects health as a human right in two ways: to seek the root of the problem (social problem), and “elicit the experiences and views of poor people” (Farmer, 146). Healthcare professionals rarely blame societal structure for poor health and this needs to change.
Farmer offers us another term, part of the solution that he eventually outlines in section two of his book. Pragmatic solidarity, Farmer argues, is solidarity (common cause of those in need) paired with pragmatism (of a practical, realistic nature). Farmer argues, “solidarity without the pragmatic component can seem like so much abstract piety” (Farmer, 146). It places an utopian type of framework on health as it fits within human rights, but stamps a practical type of function on it when it comes to action: “heal the sick” (Farmer, 148). These two ideas are almost contradictory, and Farmer spends a good deal of his remaining pages trying to fit both within the same agenda. Utopianism, he admits, is lofty and often unpractical, but is required for the equity of all humans seeking adequate health. He ends up with this definition: “the rapid deployment of our tools and resources to improve the health and well-being of those who suffer this violence” (Farmer, 220). This starts the beginning of Farmer’s discussion on the need to “expand the concept of rights to include social and economic rights” as they pertain to health as an inalienable human right (Farmer, 221).
Farmer makes many bold claims when discussing the need for a shift in the interpretation of health and human rights. In reference to human rights agreed on in the Universal Declaration of Human Rights, “States large and small—but especially large ones, since their reach is transnational—violate civil, economic, and social rights; and inequality both prompts and covers these violations” (Farmer, 222). He also argues that placing all hope in the normative legal framework that human right’s currently operates in is “unwise” (Farmer, 223). He states “The health and human rights “angle” can provide new opportunities and new strategies at the same time that it lends strength and purpose to a movement sorely in need of buttressing” (Farmer, 223). This new health and human rights “angle” is grounded in pragmatic solidarity, while PS itself is grounded in utopianism and structural violence. Farmer also argues that bringing human rights contradictions to light is not enough; we must act with humility and acknowledge our participation in a global system that, while benefitting us, has caused an assault on the dignity on billions of the world’s poverty-stricken (Farmer, 224). Farmer even goes so far as to say that liberation theology pushes for “preferential” treatment of the poor, “[to fight] to protect the rights of the vulnerable, over and above the rights of the powerful” (Farmer, 227). This kind of foundation for health and human rights lets emerge a new perspective emphasizing new social and economic rights (Farmer, 225).
Farmer begins his discussion on the solution with a stream of additional criticisms of the current human rights system: moral relativism, high-minded charters as utopian strategies, white-ivory discussions, too much analysis, misery as “ubiquitous,” soft-headed thinking, the blaming of local custom, and law as ideology tied to power (Farmer, 231, 232). Farmer argues that the new agenda springs from preferential treatment to the poor, and that the new shift is coherent with the Universal Declaration of Human Rights (Farmer, 238). These pragmatic steps are as follows: make health and healing the symbolic core of the agenda, make provision of services central to the agenda, establish new research agendas, implement a broad education mandate, achieve independence from powerful governments and bureaucracies (collaborate with community based organizations), and secure more resources for health and human rights (states and organizations shift priorities) (Farmer, 240-245). Ultimately, Farmer argues, medical services need to be delivered urgently while still tightly tied to social and economic rights (Farmer, 244). Health as a human right must be taken as seriously as other human rights, Farmer concludes (Farmer, 246).
CRITIQUE – Strengths and Weaknesses
Farmer is effective at revealing the hypocritical nature of large countries when it comes to human rights abuses. In several different examples he highlights human rights violations in western countries, and then analyzes exactly why they go unnoticed. He notes “human rights discourse is at times so divorced from reality that an “alternative language” is necessary if we are to speak of the “rights of the poor”” (Farmer, 221). This causes the globe’s poor to hold human rights doctrines in suspicion. Farmer states the use of torture is a clear violation of human rights, yet “it is equally clear from, for example, the reports of Amnesty International, that the great majority of states systematically engage in torture” (Farmer, 221). It is hard to argue with the hypocritical violations that Farmer highlights: Russia’s treatment of tuberculosis in prisoners, US treatment of prisoners in Guantanamo Bay, Argentina’s dirty war against leftists. Farmer exposes the hypocritical nature of large governments regarding health as a human right.
Farmer does a good job deconstructing the mechanisms that typically analyze and discourse human rights. He says, “To subject to scrutiny the mechanisms which render life painful, even untenable, is not to neutralize them” (Farmer, 224). He brings up an excellent point: simply bringing to light human rights violations (in reference to health as well as other types of violations) is not enough. It is still important, but it must not stop there. He is critical of “ivory-tower engagement” and “seminar-room warriors” (Farmer, 224). It is possible to forget the voices of the suffering as we sit in an air-conditioned office or lecture hall, we must not stop hearing the often silent voices of the poor. This type of community based listening and interacting will convince the hurting people that international organizations are not based on cost-effectiveness alone, and are willing to stand on the side of the poor (Farmer, 226). These are all excellent points in my opinion. We see this in Afghanistan: Gen. David Petraeus said in the fall of 2010 “Money is ammunition; don’t put it in the wrong hands. Remember, we are who we fund” (Petraeus, NPR). This point hits hard with human rights, including health as a human right. Nations must be careful how they appear: how can a nation that seemingly supports a military junta in Haiti (providing it with weapons and training), also retain the importance domestically and internationally in helping care for the global sick and poor, as it agreed to do when it signed the Universal Declaration on Human Rights?
Another strength of Farmer’s book is his critique on the “narrow legal framework” of human rights (Farmer, 217). This type of single-mindset can obscure the true nature of a violation. Farmer uses the example of Russian prisoners, many of which have multi-drug resistant tuberculosis (MDRTB). Giving these prisoners the standard tuberculosis medication does nothing, yet aid organizations and the state continue to do so. In the western world MDRTB treatment is possible, and death is averted, yet these prisoners almost surely die from MDRTB because giving them the effective medication is not “cost-effective” (Farmer, 217). Assuming cost-effectiveness legally hides this type of human right’s violation. Instead, health and human rights, and I would agree, need to adopt mechanisms of analysis that go deeper. These mechanisms would look at the underlying factors surrounding potential human rights violations to establish more effective treatment.
While Farmer’s book has some strength, it is not without weaknesses. An example of this weakness is his point on efficiency vs. equity: “efficiency cannot trump equity in the field of health and human rights” (Farmer, 241). Equity is important, I understand that fully, but Farmer seems to dismiss the notion of sustainability, cost-effectiveness, and practicality. Sustainability is VITAL in nearly every state, organization, business, and individual’s plan. I am reminded of the Brundtland Commission (welcomed by the UNGA in resolution 42/187), which emphasizes sustainable development as meeting a need, while not compromising the ability of future generations to meet that need. Sustainability is such a crucial factor in the furthering of all human rights, that it seems unwise that Farmer casts it aside in importance to equity. Equity is unachievable if it is unsustainable.
Another critique I have of Famer’s work is this: establishing a “new research agenda” takes away the neutral power of research (Farmer, 241). I understand his desire to educate people on the need for the inclusion of health as a human right, but he pushes it too far, attempting to sway the outcome of research before it is conducted. He states “The purpose of research should be to do a better job of bringing the fruits of science and public health to the poorest communities” (Farmer, 242). While this sounds innocent enough, it actually forces a directive on students to produce an intended result. This is not true, objective, research. Education is not meant to set things right, but rather to educate. Farmer attempts to hijack the vehicle of education, however well suited for the task, and forces it to achieve a certain purpose.
Farmer goes too far in attributing the poor as a direct result of the rich. He suggests that structured violence is to blame, and that liberation theology offers some “insight” into the health dilemma (Farmer, 139, 140). Liberation theology, since it assumes that the poor are more at risk to be sick, allows for an “indisputable association… to devote itself (medicine) to populations struggling against poverty” (Farmer, 140). He quotes several authors who argue for preferential treatment of the poor. This goes against another central theme in his book: equity. One of Farmer’s central points is the “equitable distribution of the fruits of scientific advancement” (Farmer, 18). Inequity certainly exists when it comes to health care and human rights, but to arrive at this point using the vehicle of liberation theology, which places the rights of the poor (in this case health) over the rights of the rich, is contradictory. Farmer states, “Our (physicians) commitments, our loyalties, must be primarily to the poor and vulnerable,” and yet a few pages later he talks about the “deepening inequality between the rich and poor” (Farmer, 229, 231). It seems to me that Farmer is switching one form of inequality for another. True equity is fair and impartial, not biased toward one group. Farmer goes so far in arguing for equity in healthcare that he creates inequity, something typical in utopian-based human rights arguments.
My intellectual paradigm found itself shifting in unexpected ways. While Farmer’s book concerned health and human rights, it also offered a heavy critique on modern medical ethics. While this wasn’t my primary focus, I now find myself well versed in medical ethic terminology and its weaknesses in modern form. Medical ethic shares many parallels with human rights, but it also varies in other areas. Medical ethics, similar to human rights, varies slightly with the excuse of local culture. This is inappropriate, Farmer argues, and I would agree, as local relativism destroys the strength of universal rights and ethics.
I also found myself more educated in reference to Article 25 in the Universal Declaration of Human Rights, as Farmer referenced it frequently to create a global base of support for most of his ideas. A whole world of literature surrounding health as a human right has been created, and I feel I know more about this article than any other now, especially the right to security in the event of sickness (UNDHR, 25.1). I also understand better the need to interpret human rights discourse through the course of other human right’s documents, like the Brundtland Commission. Human rights issues are certainly not black and white, although declarations and other official documents often present them that way. The issues may even be contradictory, and require a sort of canonization against other official documents.
Politically, the book affected me in a few big ways. First, I realized the soft spot I have for those suffering. As a Christian, politically, I often find myself torn between welfare and libertarianism; essentially how much compassion a Christian should turn into action? I was able to deal with these mainly internal, political conflicts as I went through the book, realizing that I’m not as conservative as I thought, and that I see the need for international action from those able to help the destitute poor. I also see Farmer’s point about structural violence as meaningful, and while I disagree with his liberation theology claims, I still see a middle road that enables us to analyze deeper societal structures as contributing to human rights violations. I tend to hold the belief that global structures of north and south are easily broken with hard work, dedication, and self-dignity. While this isn’t necessarily untrue, I also see the structural barriers some people simply can’t break free of.
I also found myself politically inclined to act instead of analyze. Politically, I forget that acting is often more important than simply acknowledging or analyzing. Studying human rights is not enough, Farmer argued, and I would agree. This will certainly affect my future mindset when it comes to health and human rights. True neutralization of suffering comes from action, regardless of the framework you have for understanding human rights or medical ethics. As a Christian I think this is true as well as we see in Jesus’ parable in Matthew 25:14-23. We are to make something with what God gives us, be leaders endowed with humility and faith, and most importantly act; we must avoid fearfully burying action like a bag of money in the ground.
Farmer, P. (2005). Pathologies of power health, human rights, and the new war on the poor (2nd ed.). Berkeley: University of California Press.
Martin, R. (2010, September 30). In Afghanistan, buying friends doesn’t buy loyalty. World News-Afghanistan. Retrieved March 11, 2011, from http://www.npr.org/templates/story/story.php?storyId=129510496
NIV Bible (p. 956). (2011). Matthew 25:14-23. New York: Zondervan.
The Universal Declaration of Human Rights. (1948, December 10). United Nations. Retrieved March 11, 2011, from http://www.un.org/en/documents/udhr/index.shtml