Pathologies of Power is an important book; it asks uncomfortable questions and questions comfortable assumptions. Paul Farmer practices what others preach – speaking truth to power.
Well researched and thorough, Pathologies includes over 70 pages of notes, a 50-page bibliography and a 20-page index. It is broad ranging, dealing with public health, human rights, social justice, liberation theology, poverty, and other issues.
The book is divided into two main sections. Part I, “Bearing Witness,” deals with Farmer’s experiences in Mexico, Haiti, Russia, and Cuba. These are often disturbing, filled with structural violence and suffering. Part II, “One Physician’s Perspective on Human Rights,” is the more conceptual part of the book, containing insights from liberation theology and proposing a new agenda for health and human rights.
Pathologies is full of stark stories of suffering people with faces, names, hopes, and dreams whom Farmer has either helped to heal or been obliged to watch suffer and sometimes die.
These stories illustrate the inequities not only of local societies, but also of our common global society. We are all participants. Being poor is no accident. Being sick is no accident. The poor and the powerless are subject to “structural violence” on a daily basis.
One of Farmer’s greatest attributes is his ability to see isolated events in a larger context. A patient’s illness is not only a biophysical phenomenon, bet a socio-economic one as well. Often this is related to gender, class, race, and other categories. Illness and death for the most part are not accidents – they are imposed on people by a system or structure. Poor people usually pay the price. It is the poor and structurally powerless who contract HIV/AIDS, TB, and other infectious diseases. It is the poor and powerless who are most often the victims of violent crime.
However, Farmer does not want us to hide behind medicine, statistics, individual ethics, or political rights and ignore the larger issues of economic and social injustice. He states that “a failure to understand social process leads to analytic failures , with significant implications for policy and practice.”
Farmer also takes to task the human rights and the medical ethics communities. Many advocates for enhancing human and political rights see concepts such as the right to vote as fundamental to human progress. Yet Farmer insists that these rights are devoid of substance without economic and social rights. Voting in an election has never prevented a poor person from dying a premature death.
Regarding medical ethics, Farmer decries the Western fixation on the life support and the right-to-die debates. Much has been written about these individual dilemmas while millions of people around the world die from TB, AIDS, malaria and other treatable diseases with little moral outcry.
Farmer forces us to question our conventional wisdom and use of words. He points out that we commonly use words such as “sustainable” and “cost effective,” but asks, what do we mean when we say treatment of TB and AIDS with costly drugs is not “cost effective” or “sustainable” in poor developing countries such as Haiti or Malawi? Are we saying that lives in New York have more value than lives in sub-Saharan Africa? He also asks another uncomfortable question – why are these drugs so expensive in the first place?
Though Farmer is talented at seeing connections and broader linkages, it is also essential to propose concrete actions and a new agenda. Analysis is one thing – action is another. While Farmer does offer some proposals such as “make health and healing the symbolic core of the agenda” and “secure more resources for health and human rights,” it’s debatable whether his agenda matches the depth of his analysis.
Overall, his new agenda seems to suffer from two problems. First, the tactics to be employed are not self-evident. The search for increased resources has been ongoing – are there new, more effective tactics to be employed? Second, given the structural nature of problems with poverty and powerlessness, is this agenda enough?
Power and economic gradients are extremely steep, and fighting them is extremely difficult. Perhaps those who fight such gradients are fighting one long defeat, but this may be a battle for long-term survival. We must first look behind our common perceptions of the causes of homelessness, disease and poverty and strive for structural change and a more equitable world.
