Pathologies of Power concerns itself with investigating the structural violence of denied opportunities, economic deprivation, violent despots (and the powers supporting them), as well as international financial organizations that harm the health of distant billions. Paul Farmer, a medical anthropologist, is concerned with the way modern medicine is driven by destructive, capitalist, neoliberal forces. These forces advocate for the dominance of competition-driven markets and ultimately results in an epidemic of what he, as well as the Haitians, term “Stupid Deaths”. Farmer uses his experience in Chiapas, Russia, Haiti and work with his organization Partners in Health to argue that disease prevention has as much to do with medicine as it does with politics and power.
Pathologies of Power, in addition to having all the characteristics of a good student ethnography, poses incredibly important questions to a global readership. Because of the depth and scope of health and human rights, Farmer’s work is deserving of the widest possible audience.
Marcus and Cushman’s idea of what constitutes the list ideal ethnographic characteristics differs from mine in that I don’t believe that for an ethnography to be successful it must maintain a third person, unobtrusive presence, nor must it make generalizations or refer to a common denominator people. Farmer notes the deeply personal stories and struggles of his patients and is unable to alienate his role as a physician to the destitute sick. His patients are as much a part of his story as he is a part of theirs. The story Farmer is trying to tell is much bigger than any one person and as such, he places less emphasis on native points of view, but rather notes how various individuals’ experience of healthcare contributes to a much larger conversation about social determinants of health and the politics of medicine. Drawing from fieldwork across the globe, Farmer unites the third-world through their shared experience of extreme suffering, not effectively conveyed by statistics or graphs but the suffering embodied as individual experiences as the result of social, political and economic factors that structure these risks.
Farmer does not focus on the everyday life of his patients, nor pay any special attention to native concepts because though the individual experiences of suffering are unique to those individuals, they are not unique to the cultures as a whole. Instead, he moves past talking about the specific people subject to poor social conditions and health standards. He incorporates these people as well as the factors that influence and are associated with their health standards and social conditions to also include accounts from doctors and experts to provide a more complete understanding. He uses a critique and deconstruction of theology, charity, and development models to investigate the unequal power relations between the first and third world as well as addresses the injustices and structural features that he hopes will create sustainable change in the conditions of the impoverished sick. Farmer uses jargon to signal his medical expertise, however, there is less anthropological theory applied to the issues of health and human rights. He argues there has almost become an expectation of suffering among the powerless and deep investigation of their suffering does nothing to redress it in the way that focusing on the politics of healthcare can. Farmer effectively structures his narrative with personal stories from his work with the dispossessed, careful academic notes, and well-chosen quotations from intellectuals, poets, and proponents of liberation theology.
Pathologies of Power challenged my way of thinking by forcing me to critically assess whose interests are being served through the framing issues in a certain way. Seth Holmes notes that:
In several chapters, [Farmer] shows that the concepts of “cultural difference,” “noncompliance,” “sustainability,” “appropriate technology,” and “local standards of care” are often utilized in the field of international health to naturalize or normalize global disparities in health care access. Brilliantly, he also demonstrates the ways in which the mainstream U.S. media misrepresents facts of social and health disparities, particularly in the case of AIDS care in Cuba and at the U.S. military base at Guantanamo Bay. (Holmes 2005)
Farmer quotes Cornell West affirming his goal of being a voice for those with none in noting that “the condition of truth is to allow the suffering to speak.” Farmer by no means disputes health as a human right, rather he reframes the issue to be concerned with those whom are at the highest risk of having that right violated. Through conceiving disease prevention in political terms and in addition to medical care, Farmer challenges the way we view health. He argues that health, “rather than technical compliance with laws or accords, must be the standard for evaluating governments, foreign policy, and the national restructuring plans of such organizations as the International Monetary Fund.” (Miles 2004) We need to pay closer attention to the specific relationships between human rights and abuses of human rights in relation to health and disease.
Farmer is aware of the potential alienation he could face for not having the answers to the questions he asks, or even for asking them in first place as “Western medicine cannot be separated from the whole web of technologies that are its parents and children: computers, certain reproductive interventions, biotechnology, and genetics, all of which are problematic in some way” (Mandler 1991). Despite Farmer’s many critiques in enabling these deeper questions to be asked, he is elevating the poor to the highest level of priority in considerations of care and medicine. He is being accountable in the struggle for health equity. However, this way of thinking (liberation ideology) is critical to exposing the correlation between intense global poverty and capitalist control of health care. Because suffering and injustice are largely a product of human action or in action, suffering exists as a result of structural violence “because poor health and death are inextricably linked to political and economic structures far outside the control of those affected by it” (Burcatio 2011). As Seth Holmes appropriately notes, “Farmer calls us both to recognize our complicity in structural violence and to engage in what he calls “pragmatic solidarity” with those who are poor” (Holmes 2005). Therefore, health “must be analysed considering deep history and broad geography, and interrelated social factors such as gender, ethnicity, and socio-economic status. Structural violence cannot be conflated with cultural differences” (Chung 2014).
Ben Brucato asks some critical questions into how the world is to realistically implement this pragmatic solidarity to improve health and human rights. He is sceptical about replacing traditional, self-reliant systems of care with increased dependence of the west “helping to further institutionalize technology-dependent modern medicine into their social infrastructure” worrying that this will “institute a wholly totalitarian system of care require constant social management” (Brucato 2011). It is a valid concern as medical technologies exist as a result of “animal testing and exploitation of the poor as human guinea pigs” as well as the “exploitation of labour and resources to manufacture the technologies and pharmaceuticals?” (Ibid).
Moving beyond the social problems that create multiple crises of poverty, such as the breakdown of subsistence living and the problems of landlessness in Haiti and Chiapas, Farmer addresses the deadly epidemic of multi-drug resistant tuberculosis (MDRTB) rapidly spreading from Russian prisons to the general population. Farmer informed the prison authorities that the only way to stop transmission of MDRTB was to treat patients with a costly and time-consuming regimen of second-line medicines. However, Russia’s prison system could not afford the drugs, nor were international donors, including the World Bank, willing to fund them. The recurring assertion that the drugs were too expensive to be cost-effective was used to effectively fan “the fires of this highly infectious disease, [generating] fear that in the long run its spread could prove disastrous far beyond Russia’s borders. Farmer uses MDRTB in Russian prisons as an example of a complex human rights problem that requires the application not of the law but of epidemiology, clinical medicine and sociology” (Stover 2004).
Addressing the issues of health and human rights is no easy task. Eric Stover displays the impossibility of blame through a series of questions related to the Russian epidemic of MDRTB:
Who is ultimately responsible (and should therefore be held accountable) for the unchecked spread of MDRTB in Russian prisons? Is it really the architects of neoliberal policies in far-off Washing ton, D.C., New York and Geneva, for failing to put people before profits by keeping the price of lifesaving drugs so exorbitantly high? Or is it the Russian authorities, for overcrowding their prisons? Or the Russian courts, for failing to process the detainees in a speedy manner and thus leaving them languishing in overcrowded and diseased quarters? (Stover 2004).
Farmer would argue that we are all to blame for the structural violence experienced by our world’s impoverished sick and, as such, all have a responsibility in addressing the inadequacies of health and human rights. Pathologies of Power does not claim to offer a complete solution to these inadequacies, but rather is successful as an ethnography in calling to attention to the social and economic rights that are fundamental to health and well-being and must be considered earnestly and honestly to invoke the alleviation of preventable human suffering.
Brucato, Ben. “Review of “Pathologies of Power”.” Ben Brucato. January 24, 2011. Accessed March 18, 2017. http://www.benbrucato.com/?p=125
Chung, Ren. “12 takeaways from Paul Farmer’s Pathologies of Power.” Ren Chung’s Blog. February 20, 2014. Accessed March 16, 2017. http://www.renchung.com/2014/02/20/12-takeaways-from-paul-farmers-pathologies-of-power/.
Holmes, Seth. “Pathologies of Power: Health, Human Rights and the New War on the Poor (review).” Perspectives in Biology and Medicine 48, no. 1 (2005): 153-156. https://muse.jhu.edu/ (accessed March 24, 2017).
Mandler, Jerry. In the Absence of the Sacred: The Failure of Technology & the Survival of the Indian Nations. Print ed. San Fransico, CA: Sierra Club Books, 1991.
Miles, Steven, M.D. “Book Review: Pathologies of Power: Health, Human Rights, and the New War on the Poor.” New England Journal of Medicine 350, no. 737 (February 12, 2004). Accessed March 24, 2017. doi:10.1056/NEJM200402123500724.
Stover, Eric. “Review: Beyond the Law: Pathologies of Power: Health, Human Rights, and the New War on the Poor by Paul Farmer.” American Scientist, 2nd ser., 92 (2004): 178-180. http://www.jstor.org/stable/27858368.
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