*: In an unusual format, this Reader focuses on my book review of the book by Paul Farmer, with a foreword by Amartya Sen. [Berkeley and Los Angeles, CA: University of California Press, 2003. 402 pp.].
[TLDR (too long didn’t read): This Reader reviews a popular book on power issues in health and their implications for human rights. For a quick overview, just read the bolded text].
1. Dr Paul Farmer’s book does not really talk about a ‘new’ war on poverty, it rather refers to the ancient one –and the author has full moral authority to write it. In vivid case studies taken from both North and South, Farmer shares with us his experiences with the violation of human rights (HR). The case studies may be depressing but, overall, they convey a message of optimism. The book not only searches for, analyses and explains the social causes of structural violence and extreme suffering, but also explores and deplores our collective tolerance of the social aberrations and abuses it describes. It centers around a well-documented critique of the liberal view of HR, which has rarely served the interests of those rendered poor.
2. Farmer advances many loosely-connected theses, among which the following would seem worth sharing:
2a. On power: The asymmetry of power generates many forms of quiet brutality. It is inequalities of power that prevent those rendered 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. Structures and not just individuals must be changed if the world is to change.
2b. On inequality: It is social and economic inequalities that deny services to those rendered poor. The promotion of equality is the central ingredient for respecting HR 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 nothing to reduce inequality.
2c. On those rendered poor: They are not the casual victims of human history; poverty is 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. Those rendered poor are not begging, they are demanding a right they were born with.
2e. 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 those rendered poor within existing social relationships. Their poverty demands that we build a different, more just social order.
2f. On public health: The right to health is perhaps the least contested social right –and yet those rendered poor bear the brunt of both preventable ill-health and right to health 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 are 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 and equality are the central challenge for the future of public health. Farmer even speaks of the ‘pathogenic role of inequity’ (!) and hence of a ‘right to equality’.
2g. On ethics: We know that relaxed ethical practices are unacceptable. But, without a social justice component, medical ethics risks becoming yet another strategy for managing inequality. Conventional medical ethics is concerned with the ethics of the individual; it is quite divorced from a social reality that hits us in the face. Social and economic rights are at the heart of what must become the new medical ethics —an ethics of distributive justice.
2h. 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 health, 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.
3. At the end of the book, Farmer makes six suggestions:
- to make health and healing the symbolic core of the agenda;
- to make the provision of services central to the agenda;
- to establish new research agendas;
- to assume a broader educational mandate;
- to achieve independence from powerful governments and bureaucracies; and
- to secure more resources for health and HR.
4. I want to imagine a world where these suggestions are applied, but in them, I fail to see the HR problems Farmer so ably depicts resolved. Moreover, I do have a few other points on which I have to disagree with him.
5. Although he complains that HR discussions have been excessively legal and theoretical, legal argument was needed to bring HR to the place they now occupy. He claims that the current HR discourse is at times divorced from reality. But not necessarily any longer: numerous organizations are now heavily involved in HR and capacity analysis in progressively more practical ways (although they may not call it HR); they combat the prevailing health/development paradigm that only uses HR as a language of what is ‘moral imperialism’.
6. Farmer, an adept of liberation theology, emphasizes suffering perhaps more than injustice (as a socialist would). Struggling for the liberation of those rendered poor is not about loving them, but rather about allying with them. To act as a physician ‘in the service of those rendered poor’ is not what it is all about. But to be fair, ‘pragmatic solidarity’ and a ‘common cause with those in need’ are also invoked by the book, which is, therefore, not free of contradictions.
7. Although Farmer says that his ideas do not demand loyalty to any specific ideology, the full scope of his theses blatantly denies this. In the end, to Dr Farmer, the health angle of HR proves more practical than approaching the problem as the need for drastic reforms in a country’s patterns of injustice. I do not see it as a matter of pragmatism; in HR work we are called to work on all fronts simultaneously. Better sooner than later, we have to embark on a process that roots out the structural problems underlying widespread HR violations. The real underlying war cannot remain undeclared (Farmer’s words). Progress will ultimately be more plausibly judged by the reduction of deprivation than by the further enrichment of the opulent (Amartya Sen). In Farmer’s words: we simply cannot feel too old and tired for justice.
8. Farmer concedes that his book is principled, but extreme. It is not harsh, though; the realities it describes are. In sum, the book is a source of innumerable pearls of wisdom, but often buried in longish paragraphs or long, though relevant, quotes. It is also somewhat repetitive, if from slightly different angles. I found Chapter 5 on Health, Healing and Social Justice particularly heavy going.
9. At the end, 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. He asks why we should give a damn. And the ‘because’ is loud and clear: it is not useless, but very urgent, to keep active in the struggle!
Claudio Schuftan, Ho Chi Minh City
Your comments are welcome at schuftan@gmail.com
All Readers are available at www.claudioschuftan.com
Disclaimer: I am aware that this was written 17 years ago, so I am guilty of not having checked whether Dr Farmer has changed his views as expressed in the book. I remain open to be rebuked and taken to task. (The book review has had over 2100 reads in ResearchGate).