Pathologies of Power: Health, Human Rights, and the New War on the Poor

by Paul Farmer, Amartya Sen (Foreword)

Pathologies of Power uses harrowing stories of life—and death—in extreme situations to interrogate our understanding of human rights. Paul Farmer, a physician and anthropologist with twenty years of experience working in Haiti, Peru, and Russia, argues that promoting the social and economic rights of the world’s poor is the most important human rights struggle of our times. With passionate eyewitness accounts from the prisons of Russia and the beleaguered villages of Haiti and Chiapas, this book links the lived experiences of individual victims to a broader analysis of structural violence. Farmer challenges conventional thinking within human rights circles and exposes the relationships between political and economic injustice, on one hand, and the suffering and illness of the powerless, on the other.

Farmer shows that the same social forces that give rise to epidemic diseases such as HIV and tuberculosis also sculpt risk for human rights violations. He illustrates the ways that racism and gender inequality in the United States are embodied as disease and death. Yet this book is far from a hopeless inventory of abuse. Farmer’s disturbing examples are linked to a guarded optimism that new medical and social technologies will develop in tandem with a more informed sense of social justice. Otherwise, he concludes, we will be guilty of managing social inequality rather than addressing structural violence. Farmer’s urgent plea to think about human rights in the context of global public health and to consider critical issues of quality and access for the world’s poor should be of fundamental concern to a world characterized by the bizarre proximity of surfeit and suffering.

Genres: Nonfiction, Anthropology, Medicine, Politics, Social Justice, Health, International Development

438 pages, Paperback

First published April 25, 2003

About the author

Paul Farmer was an American medical anthropologist and physician. He was Professor of Medical Anthropology at Harvard Medical School and Founding Director of Partners In Health. Among his books are Infections and Inequalities: The Modern Plagues (1999), The Uses of Haiti (1994), and AIDS and Accusation: Haiti and the Geography of Blame (1992). Farmer was the recipient of numerous awards, including a MacArthur Foundation "genius" award and the Margaret Mead Award for his contributions to public anthropology.

Farmer was born in the U.S.A. in 1959. He married Didi Bertrand Farmer in 1996 and they had three children. He died in Rwanda in 2022, at the age of 62.

Reviews

[Nicole]

I really wanted to read this book. I was excited when I found the audiobook because I can't read nonfic for the life of me. So audiobooks it is.

This is one of the worst audiobooks I have yet to come across. They say a narrator's name yet it sounds like a robot reading. Google translate like. It gave me a headache and I couldn't' make it past 8 min.

Don't bother with the audio. Now, who knows when I'll be able to read the book.

[Simon Wood · Rating 5 out of 5]

FARMER IN THE FIELDS OF HORROR AND HOPE

I have known of Paul Farmer for years, principally through footnotes in his fellow Bostonian Noam Chomsky's books (whom Farmer thanks in his acknowledgements to this book) and in a variety of other books and articles over the years, and I thought it was about time that I became better acquainted with his writings and managed to get my hands on a copy of his 2004 book "Pathologies of Power".

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.

[Mehrsa · Rating 5 out of 5]

Efficiency cannot trump effective treatment. When capitalism infused with racism is in charge of healthcare, people die from preventable diseases. Farmer is a modern prophet in this field and shines light on structural issues of poverty. As he says, deaths of poverty are crimes against humanity. This is fixable--we just have to care. Also, he's a great writer.

[Meg Petersen · Rating 5 out of 5]

This probably isn't most people's idea of recreational reading, but Farmer's view of the aid community and how first world powers use aid and don't aid when they should really resonated with me. It's an angry book from one who knows just how angry we all should be. This has me looking for more of what he has written. I am particularly interested in more about Haiti. It wasn't always comfortable. We are all complicit in this and I could feel my own complicity as I read it. I thought about parallels between the situations he describes in health and my own work in education.

[The Conspiracy is Capitalism (episode 2 is out!) · Rating 3 out of 5]

Humanitarian physician/anthropologist Paul Farmer uses his privileges as a Harvard prof to challenge several pillars of the American establishment, to bear witness to the impoverished (Haiti, Chiapas, Russian prisons) by outlining causes/effects of structural violence:

1) American foreign policy: inescapable, yet Western ideological censorship does wonders!

2) Market Liberals/technocrats: Farmer cites the great saying that Liberals think bad things in the world stem from accidents! This root of imperialism needs to be unearthed from various perspectives. Farmer mostly details this on a micro-level policy perspective, unpacking notions of "cost-effectiveness" and "self-sustaining". Farmer also references Liberation Theology numerous times, as one of the few frameworks dedicated to the impoverished.

For broader analysis, Ha-Joon Chang dispels beginner myths of "Free Market"/Capitalist development, while Vijay Prashad, David Graeber, Michael Hudson, Michael Perelman and Silvia Federici dive deeper...

3) Human Rights law: this field, dominated by lawyers and institutionalized by States that account for an overwhelming amount of human rights violations, has a lot to answer to.

4) Healthcare professionals: in this field's ethics, where is socioeconomic status and its structural violence?

At times meandering (it seems Farmer compiled a series of essays), this book nonetheless brings together several key fields and adds unique insights.

[Maureen Flatley · Rating 5 out of 5]

This book by the brilliant physician and human rights activist, Dr. Paul Farmer, is the single most trenchant analysis of our global human rights crisis I have ever read. Weaving together the inescapable links between poverty, food, shelter and healthcare, Dr. Farmer's book is a damning indictment of the international aid community.

[Maura · Rating 4 out of 5]

This book is every human rights activist's dream come true, because Farmer documents his efforts to provide quality health services in poor communities around the world, and he shows how the struggle for adequate health care is unavoidably connected to the struggle for other human rights.

Through various case studies, Farmer demonstrates that, contrary to the claims of most governments and international agencies, public health crises in poor communities can in fact be avoided. Most governments and international agencies primarily concern themselves with the cost effectiveness of addressing health crises in poverty-stricken areas; Farmer demonstrates how small things-—like providing patients with a small stipend to buy more nutritious food, giving out mosquito nets, or providing transportation to health clinics-—can prevent disease and increase patients’ chances of recovery. He shows that rather than treating a disease or an individual patient, investments must made in the whole community. Much of his discussion focused on foreign countries, but I was glad to see that he also addressed the U.S.’s denial of adequate health care to the poor. Throughout the book, he stresses that structural violence is the root cause of premature deaths among the poor, and therefore structural violence must be addressed if human rights are to be protected. I appreciated his observation that the human rights movement is also partially to blame for public health crises, because it has largely failed to adequately fight for the recognition of health care as a human right.

Since I don't have a medical background, I found his case study on multi-drug-resistant tuberculosis particularly informative, because he explains how governments and well-meaning international aid organizations can actually make things worse by only partially funding efforts to control TB. Treatment of TB requires intensive and expensive drug therapy, but if patients get the wrong type of drugs, or receive them at the wrong time or in insufficient quantities, their symptoms worsen and the virus becomes even more resistant to drugs, thus further endangering the patient and the public. Farmer uses this to illustrate his main argument: that only substantial, long-term community investments can truly protect the health and human rights of the poor.

Overall, I found Farmer to be incredibly well-informed, eloquent, and thoughtful. Oh yeah, and one of things I appreciated most: nearly all the books I read are 'downers,' ie, they talk about all the depressing problems that plague humanity without really proposing any solutions. Farmer not only discusses solutions, but his case study of Haiti demonstrates how he's actually been able to make a difference in people's lives by tying the struggle for health care into the struggle for other economic rights--access to nutritious food, clean water, transportation, etc. Unlike most books of this genre, it didn't make me feel like giving up in despair--instead, I pulled out my checkbook, and have been donating regularly to his org ever since, because I find their work incredibly admirable and important.

The only reason I'm giving it 4 instead of 5 stars is because I found it a bit dry and hard to get through. I also felt his chapter on the Zapatistas didn't flow well with the rest of the book.

[Harrison · Rating 4 out of 5]

Paul Farmer’s Pathologies of Power is a written protest against the structural violence suffered by the poor. The first half of the book is devoted to anecdotes from his time spent in the rural highlands of Haiti, the HIV quarantine facilities of Guantanamo, the autonomous zones of Chiapas, and the prisons of Russia. Through these anecdotes Paul gives voice to the suffering poor in these areas in a way that neither dehumanizes nor romanticizes their suffering, a rare feat in literature about poverty.

As a physician, Paul focuses on the ways in which this suffering is experienced through degradation of health. Particularly shameful in these stories is the extent to which the poor suffer and die from curable diseases. “Li mouri bet,” Paul bemoans in Creole at the death of a young man from an infection, “what a stupid death.”

The poor live Hobbesian lives—nasty, brutish, and short—partially because of our market-based approach to medicine in which health is the exclusive privilege of those wealthy enough to afford it. Instead, Paul calls for a far different approach to medicine based on human rights, in which the benefits of medical knowledge developed collectively by the human race are made available to all as their birthright. Health, Paul argues is not a privilege of the rich man, but the right of every person.

In particular, Paul rails against the aid and development community obsessed with “cost effectiveness” who mark the price of a Haitian life shockingly low—less than the cost of a round of antibiotics necessary to treat multi-drug resistant tuberculosis. Complacent in the charity model of health care, the global heath community timidly seeks only to provide the low quality care afforded by the castoffs of the rich rather than call into question the structural violence that keeps the poor in poverty.

Drawing heavily from liberation theology, Paul argues for a reorientation of societal values toward the preferential option for the poor. From the diabetes of Americas urban slums to the HIV of sub-Saharan Africa, the poor bear the majority of the disease burden, and so Paul calls especially on physicians to lead this priority shift to the poor by focus their efforts on those that need their care, not just those that can afford it.

More than some nominal increase in the American aid budget, what is called for is the recognition of the inherent rights of every human being regardless of nationality. This entails the coordinated effort to secure those rights not merely through the charity of the rich, but through the profound alteration of those structures which deprive people of these rights in the first place.

It’s a bold challenge, to be sure, but one of the first that actually has hope to establish a just global society.

Paul's style of writing is sometimes meandering and disjointed which is why I can't give the book 5 stars, but all in all this book is a must-read for anyone interested in global health or human rights.

[Faye · Rating 4 out of 5]

I read Mountains Beyond Mountains by Tracy Kidder which is about Paul Farmer, this is the first book I have read written by Paul Farmer. He calls himself a physician and an anthropologist which makes a lot of sense from what I know about him. I also saw Tracy Kidder speak once and talk about his experience learning about and becoming friends with Paul Farmer. In Pathologies of Power he talks about "structured violence" against the poor around the world and he points out that the lack of social and economic justice which is a form of violence (denying access to jobs, food, and medical care) and that what happens to the poor is not random.

I can't believe I started reading this book and the earthquake in Haiti happened a week later. God, there is just so much suffering there now and has been in the past. He is comparing the treatment of AIDs patients from Haiti in Guantanamo and comparing it to the HIV sanatoriums in Cuba. He documents eye-witness and victim accounts and shows that the conclusions for each case are exactly the opposite as portrayed in US media outlets. In a moment of cynicism Farmer states: "Granted that in this postmodern moment, when we are told that only willfully naive positivists seek something called the truth, it is important to acknowledge that more than one discrepant version may be true in some important sense. But some versions, surely, must have more points of contact with external reality and actual events than others." I wonder it the failure of US foreign policy with Haitians in and outside of Haiti will come out with the earthquake disaster?

At the end of this book Farmer summarizes a new agenda for health AND human rights with 6 points: 1) Make health and healing the symbolic core of the agenda (not profits), 2) Make provision of services central to the agenda (for the poor), 3) Establish new research agendas (to make drugs and other therapies cheaper), 4) Assume a broader educational mandate (beyond health professionals), 5) Achieve independence from powerful governments and bureaucracies (that are so often human rights violators), and 6) Secure more resources for health and human rights (social and economic justice).

[Taariq Hassim · Rating 4 out of 5]

'Progress is more plausibly judged by the reduction of deprivation than by the further enrichment of the opulent. We cannot really have an adequate understanding of the future without some view about how well the lives of the poor can be expected to go. Is there, then, hope for the poor?'

[Gina · Rating 2 out of 5]

My main takeaways from this book were an appreciation for the lyrics of Bertold Brecht and some additional knowledge about tuberculosis in Russia and AIDS in Haiti from around the year 2000. That is not without value.

It is easy to see how the structural violence is turned against the poor on the matter of health, and to see the importance of health, and how it is tied in with access to food and clean water and all of the obvious things. And maybe that's the problem, is that it is kind of obvious. An eloquent essay could have done just as well. (Actually, I don't remember, but an eloquent essay that referenced this book might be how it ended up on my reading list.) Of course, I am someone willing to believe that healthcare is a human right, and that the structural inequities need to be fixed. Someone who was not on board with that would probably not find the additional detail helpful.

That made it harder to ignore the flaws of the book.

Incidentally, there are no solutions offered. The point is to convince people about the importance of prioritizing the health of the poor, and I think people who need the book will not be convinced by it.

Beyond that, the books starts out with some criticism of neoliberal policies. That can be valid, but that wasn't explored, as that was not the topic of the book. Instead, it was brought up as a criticism and kept, and years later it is hard to not read that as the words of someone who will tell you that both parties are the same, after years of devastating evidence that they aren't. Maybe it just hasn't aged well.

Because of the points mentioned, every time the author mentioned being an anthropologist (as well as a doctor), I kept flashing back to very colorful criticisms of anthropologists that I have read from Native American authors.

Still, Brecht seems great.

[Paul · Rating 5 out of 5]

"Pathologies of Power" is a very important resource for those seeking to understand and morally diagnose the obscene global inequalities in health. Dr. Paul Farmer is an intimate witness to the suffering and struggle of the global poor and neglected. Farmer's voice is deeply prophetic in both exposing the "structural violence" towards poor people by depriving them of the necessary conditions and resources to live healthy and hopeful lives, and advocating passionately on behalf of those catching hell by challenging the powers responsible for their dehumanizing plight. The book drips with a moral rage for what is going down, containing numerous accounts of human despair due to premature dying and disease. It is full of cutting accusations and judgment, especially towards human rights organizations and bioethicists whose tasks are to raise consciousness and promote change for health justice. It is a book of social protest. But it does not come across as some annoying screed by a pompous man/woman of (false) righteousness. His bluntness and harshness seems justified in the injustice and indifference that he is witnessing. His social/moral critique is rooted in a perspective that is totally informed as a physician of the poor/anthropologist/academic and nourished by the ethical framework of liberation theology. One may disagree with Farmer's conclusion that the health inequalities that we are all witnessing are unjust and therefore we have a moral responsibility towards the nearby/distant needy to assist them, but one should not develop a moral position to this concrete human dilemma without confronting the brutal reality and analysis that Farmer paints with prose full of eloquence and urgency.

[W. Littlejohn · Rating 4 out of 5]

It's books like this that make me temporarily enraged with America, its obscene affluence, and hypocritical Christian support of it, and that make me want to abandon my trek toward academia and do something more useful, like helping the oppressed.

Edit:
I should add that I'm not actually sure whether I should give this book 4 stars. From a Christian and theoretical standpoint, it's very lacking. He is not himself a Christian, and though he claims to draw on the insights of liberation theology to formulate his argument against "structural violence," he evacuates liberation theology of anything theological in the process, leaving his resources for combatting the evil he sees very vague and limited indeed. In particular, the notion of "structural violence" could be much more developed within a Christian framework of sins of omission--the neglect of responsibility, at individual and corporate levels.

But I'll keep it at 4 stars, since he gives a very powerful portrait of the problems out there, and so succeeds well at his primary objective. If his primary objective were to articulate a solution, he would have failed rather badly.

[Joel Doetsch · Rating 3 out of 5]

I couldn't really get into this book. It's possible that I misunderstood the overall thesis of the book.

He did a very good job going into details of rights abuses in various parts of the world (mostly Haiti). What was missing for me was some sort of unifying theory or framework to deal with these abuses. It just didn't really draw me in.

[Tatiana · Rating 5 out of 5]

This book is a clear call to action. If you've been following my reviews, you know that I've had an epiphany of sorts from following Dr. Paul Farmer's work. He's the doctor to the poor, the one who cofounded Partners in Health, which treats poor people in nine different countries all over the world, in some of the settings of extreme poverty. They've been working in Haiti for about 25 years, since the early 80s.

His books have raised my awareness of what's actually going on in the world. This is real stuff. It's ongoing, it's actually happening right this minute even, it affects several billion people, it's deeply, deeply wrong, and it's our business to fix it. Paul's analysis has helped me to understand that this is very much my problem. Poverty is the connection, the thing that puts people from all different cultures, in all different places, at high risk for diseases of all types, for violence, for oppression. The story of global health is largely the story of poverty.

Secondly, he has shown me that my relative wealth (I have clean water, nutritious food, decent shelter, warm clothing, education, and access to information) is not independent of their destitution, but in fact that I benefit from the global forces that transfer wealth from the poor to the rich and have done so for centuries. I'm the direct beneficiary of the organized theft that puts these people (my kin and fellow children of God) in a position to be tortured, raped, to fall ill and not receive care, to be malnourished, and kept ignorant. So it's up to me to fix it.

I want to quote for you a passage from his afterword, from his summing up.

The spectacular aggressions I have witnessed are not accidents. Arising from complex social fields, these crimes are predictable, and indeed, ongoing. They are, I have tried to show here, pathologies of power. Looking through piles of notes and articles gathered to complete this book, I am reminded of many stories that are not told in these pages. I did not write about my patient who was the victim of a brutal gang rape inside military headquarters in Port-au-Prince. She told me that one of the most debasing moments of her experience was hearing the army's lawyer, a smartly dressed woman who spoke beautiful English, say on CNN that stories of political rapes were simply not true, that the alleged victims were lying to discredit the Haitian army. To see these and similar claims subsequently taken up by reputable international print media was painful enough for me; I couldn't bear to discuss it with my patient.

Nothing is written in these pages of the thugs who in 1988 torched the church of Saint-Jean Bosco during mass, or, even worse, of the paltry sum it cost the mayor of Port-au-Prince to have them do it. Yes, the mayor (who is no doubt also getting on in years, although he has yet to reach the golden age of Pinochet (a reference to Pinochet being thought too old for justice. -T) Even though one of my closest friends was among the survivors, and even though I have written about these events, I have never discussed them with this friend, and I never will.

And on and on. These events are added to a long list of things I wish I had not seen, or heard, or smelled. Indeed, staring at the x-ray image of the bullet in Manno's leg (a reference to a child victim of violence in Haiti who was not helped at all by doctors at the regional hospital in Port-au-Prince. -T) triggers recollection of many expediently forgotten bullets and their forgotten targets. I stop to recall, however briefly: in 1987, sewing up a child's gunshot wounds in the same general hospital from which Manno was just extruded; evaluating the surviving victims of a grenade pitched into a 1990 pro-Aristide rally; knowing what it looks like to watch, from the middle of a traffic jam, a crowd fired upon by automatic weapons, an anonymous ten-year-old boy caught in the crossfire; the death of Chouchou Louis (a torture victim described earlier in the book. -T) in my presence; and the burning alive of secret police, killed by angry crowds. The even worse smells of morgues and prisons and deathbeds crowd my senses.

And the assaultive truths don't stop with the things that I have witnessed, since many of the stories I've heard from others elsewhere have a specific resonance for someone who has worked in Haiti. I think here of the exhumation in Guatemala, with which we did indeed help, and of the one unmarked grave that contained a young man, his wife, and their unborn infant (one bullet was within the fetus). I think of my friend "Julia's" martyred brother -- a teenager, for God's sake -- his body displayed like a hunting trophy; the "disappeared" in Haiti and in Central America; the murder of Father Jean-Marie Vincent by the Haitian military. Father Vincent died, gasping like a fish, on the steps of the rectory.

What do all of these victims have in common? Not language or gender or political views; not religion or race or ethnicity. What they share, all of them, is poverty and, generally, an unwillingness to knuckle under. Pathologies of power damage all concerned -- and who isn't concerned? -- but kill chiefly the poor. These crimes are the symptoms and signs of structural violence. Indeed, when we regard the perpetrators of these crimes from any comfortable reserve, it is important to recall that with our comfort comes a loss of innocence, since we profit from a social and economic order that promises a body count. That is, surely there are direct and causal relationships between a protected minority enjoying great ease and those billions who go without the bare necessities of food, shelter, potable water, and medical services? Pathologies of power are also symptoms of surfeit -- of the excess that I like as much as the next guy.

He goes on to ask a burning question: "is it really useless to complain?"

He goes on to contemplate his own loss of innocence, and to ask from whom he can demand it back.

My own answer to that question, protected as I am from the harsh truths of the depth of violence of poverty, yet from my own position as a survivor of childhood abuse, and the adoptive mom of a son who survived much worse than I... my answer is that Christ, also a victim of torture, had my innocence, that he gave it back to me when I begged him for it. My answer is, like Paul, to dedicate my life to ending poverty.

All I want is for every child born on earth to have love, good care, clean water to drink, adequate nutrition to avoid developmental disabilities, decent housing and bedding, freedom from violence, shoes and clothing, adequate health care, to get good treatment for all treatable diseases, and to have access to the wealth of knowledge, of education, that our modern communication systems afford. I want an end to bigotry, to racism, sexism, classism, jingoism. I want all of us to help one another, to take care of each other and share each other's burdens. That's all I ask. And I think it's the least we can do. The very least.

I don't insist that it be done instantly. (Though really how can we accept the damage to any child that results from delays?) I know that what we don't finish, the next generation will complete for us, along with dealing with whatever new challenges arise for them. I don't have to do it all myself. But it will be done. Make no mistake.

Sekhmet is the Egyptian goddess of protective wrath. She's sacred to mothers everywhere, and she looks after the weak and powerless. Well, Sekhmet is definitely on the move now. She's kicking butt and taking names. She's sort of like Santa, but a lot more wrathful. She's sometimes depicted with a flamethrower, her Flammenwerfer of Ruinous Wrath. Please be aware of her oversight. Be mindful of her FoRW.

Take care that you are not among those who leave undone what should be done, for Sekhmet is watching, and she will know and remember.

[Nic · Rating 5 out of 5]

Wow! The notes alone! The notes are referenced to the page numbers, which is so handy, especially when you're flipping back and forth between the notes and the text. I'm beginning to think, after reading a few books, written by anthropologists, that this is unique to their style, having these referenced notes. Everyone should do this! The notes are supportive of the text and include some additional treats as well. Here are a few of my favorites:

Chapter 2. Note 67. Referencing an essay by Noam Chomsky "David vs. Goliath." And Cuba, unfortunately, keeps making that clear, for example, by sending doctors all over the world at a rate way beyond any other country despite its current straits, which are severe, and by maintaining, unimaginably, a health system that is a deep embarrassment to the United States. Because of concerns such as these, and because of the fanaticism that goes way back in American history, the U.S. government, for the moment, at least, is continuing the hysterical attack, and will do so until it is deterred. 283

chapter 3. Note 8. This note is a letter from Subcomandante Marcos to some schoolchildren. Here is just the ending/signature of that letter.
That is why, boys and girls of Jalisco, we began our war. That is why the peace that we want is not the peace that we had before, because that wasn't peace, it was death and contempt, it was pain and suffering, it was disgrace. That is why we are telling you, with respect and love, boys and girls of Jalisco, to raise high the dignified flag of peace, to write poems that are "Prayers for a Dignified Life," and to search, above all, for equal justice for everyone. 288

Chapter 5. Note 35. On liberation theology, which Farmer is a strong proponent of. Samuel Johnson once observed that "a decent provision for the poor is the true test of civilization." Surely this is true, and it serves as an indictment of affluent society. But liberation theology delivers an even more damning indictment since its proponents argue that we should reserve our highest standards for the poor. 302

Chapter 6. Note 6. A July 2001 report by Families USA finds that"all of the nine U.S. pharmaceutical companies that market the top-selling 50 drugs for seniors spent more money on marketing, advertising, and administration than they did on R&D" (Pollack and O'Rourke 2001, p.3). And six of these companies made more money in net profits than they spent on research and development. A goodly portion of the money went to pad the pockets of chairpersons, CEOs, and vice-presidents. The twenty-five highest-paid executives for these nine companies garnered a total of $331.6 million in compensation- not counting unexercised stock options - during the year 2000 alone (ibid., p. 5). 304

Chapter 6. Note 7. ...newspaper advertisement run by a destitute shantytown dweller in the early 1980s: "I am wiling to sell any organ of my body that is not vital to my survival that will allow me to feed my family" 305

Well, I have a whole list of notes quotes to include, but it's getting too lengthy. If you read this book, which I recommend, please do not skip over the notes.

I read this book because my church supports a sister Parish in Chiapas, and I wanted to hear about Farmer's work in Chiapas. Chapter 3 of the book is Lessons from Chiapas. My favorite quote from this chapter: As one early (and exceptional) bishop of Michoacan put it, "It would seem that the Spanish brought Christ to America in order to crucify the Indian." 105

So, to try and encapsulate the gist of this book? Structural violence creates "Pathologies of Power". These pathologies manifest in the poorest members of our societies, the victims of structural violence. Therefore, it is the duty and obligation of the powerful to right these wrongs by ensuring that those who suffer these pathologies have access to healthcare. And, not the least of healthcare, not the leftovers, but the best that healthcare has to offer. The same care that those in power have access to. Farmer suggests that liberation theology is a good route to follow in ensuring equal access to healthcare for the world's poor.

...access to the fruits of science and medicine should not be determined by passports, but rather by need. The "health care for all" movement in the United States will never be morally robust until it truly means "all." 153

Those who believe that charity is the answer to the world's problems often have a tendency - sometimes striking, sometimes subtle, and surely lurking in all of us - to regard those needing charity as intrinsically inferior....There is an enormous difference between seeing people as the victims of innate shortcomings and seeing them as the victims of structural violence. Indeed, it is likely that the struggle for rights is undermined whenever the history of unequal chances, and of oppression, is erased or distorted. 153

...charity medicine too frequently consists of second-hand, castoff services - leftover medicine - doled out in piecemeal fashion...The notion of a preferential option for the poor challenges us by reframing the motto: the homeless poor are more deserving of good medical care than the rest of us. 155

But the experiences of those who are sick and poor - and, often enough, sick because they're poor - remind us that inequalities of access and outcome constitute the chief drama of modern medicine. 164

Fifty years after the introduction of combination therapy that is almost 100 percent effective, tuberculosis remains (along with AIDS) the world's leading infectious cause of readily preventable adult deaths...If the World Health Organization is correct, tuberculosis killed between two and three million people in 1997 - more than died that year from complications of HIV infection, and perhaps more than have died in any one year since 1900. And this happens in almost complete silence, in large part because tuberculosis victims are usually poor. 168

One of the central points of this book is that public health and access to medial care are social and economic rights; they are at least as critical as civil rights. An irony of this global era is that while public health has increasingly sacrificed equity for efficiency, the poor have become well-informed enough to reject separate standards of care. 217-218

Another very important point Farmer makes is that even though we have the Geneva Conventions and the Universal Declaration of Human Rights we still have horrible crimes against humanity occurring over and over again. Is it grandiose to seek to define a new agenda? When one reads the powerfully worded statutes, conventions, treaties, and charters stemming from international revulsion over the crimes of the Third Reich, it might seem pointless to call for better instruments of this sort. Yet events in the former Yugoslavia and in Rwanda serve as a powerful rebuke to undue confidence in these approaches: "That it should nevertheless be possible for Nazi-like crimes to be repeated half a century later in full view of the whole world" remarks Neier, "points up the weakness of that system - and the need for fresh approaches." 238

Well, I'd better stop with the quotes. There's so much more that I'd like to include. This is an important work Paul Farmer has shared and I hope many read it. Hopefully, after reading, some will feel compelled to help, in any little way, in their corner of the world, to right the wrongs.

[Jake Losh · Rating 2 out of 5]

This is a detailed book with nuanced arguments and heart-rending stories of the travails of the poor and underserved. As a newcomer to discussions of human rights, social rights and access to health care – indeed, health care generally – I welcomed the perspective that Paul Farmer brings in this well-written book. I'd also call out that everything is scrupulously cited and noted. Indeed, the notes are a significant chunk of the text and full of great details.

The crux of Farmer's argument is that the human rights community (i.e., all of us humans?) need to take more of a multi-dimensional and refined view of what constitutes human rights and rights violations – making particular note of how structural violence factors in. On considering structural violence, he argues that economic rights should be added to the list of human rights. He provides ample anecdotal evidence for the existence of structural violence and the need for multi-dimensional analyses and plenty of stylized facts on poverty as violence. Ultimately, I was promised an analytic framework for identifying systemic violence and human rights violations and he did not deliver. His arguments that economic rights should be added to the list of human rights were also not well-supported.

The introduction was excellent and I might even recommend one stop after reading it as all the argumentative meat is there. Part I of the book, "Bearing Witness" was a tiresome recap of all the awful things that have happened in Haiti, Chiapas and Russia in the past thirty years. This section was moving, but I kept wondering when the argument was going to come in. In keeping with the mantra of observe, judge, act that Farmer touts, I guess this is a sensible thing to do, to give a lot of space for sharing the voice of the underserved, the silenced and the ignored, but other than the overarching principle "where there are poor people, there are human rights violations" I didn't get much in the way of an analytic framework. All of this is terrible, yes, and it's important to understand the history of these places and the ways governments (including my own) perpetuate violence against the systemically oppressed, but it's also past tense. And Farmer offers basically nothing other than protest as an engine for change. It's very much a politics of opposition as opposed to a politics of governing, a common criticism of Marxism.

Part II, "One Physician's Perspective On Human Rights", is where we're supposed to get more of the meat of his arguments. I suppose that the audience of this book is already on board with the idea that the list of human rights should be expanded, but this is not an uncontroversial opinion. Many philosophers would rather take a minimalist view of human rights, objecting that the social rights Farmer takes as given do not serve truly fundamental interests. Further, I kept searching for the practical side of things: How are governments, particularly those of developing nations, going to pay for the medical care that Farmer says we can easily and cheaply provide (assertions I'm incredulous to)? Is a violent overthrow needed? If so, this falls back into the politics of opposition that I noted before, which will make the state ungovernable and especially vulnerable to the special interests we're decrying here. Will we make the rich in these countries pay? Not in a world where people – especially the wealthy – and capital are mobile. Will we shame developed countries into owning their systemic oppression of the developing world's poor? This is clearly not in the interest of the vested power structure. As a final thought on Farmers claims on economic rights as human rights, what about the Whitehall studies, which seem to indicate that extra-economic factors like prestige seem to matter more than pure economic status? What are we to make of the idea of economic rights in the face of such evidence? Farmer correctly highlights the pitfalls of charitable aid but I think he doesn't give development approaches to tackling systemic poverty enough credit. What am I to make of China and India and the millions of people being lifted out of poverty in these countries? And what of Japan and South Korea's experience? Or even the United States' historical experience? Perhaps he should have consulted an economic historian? Instead, I get patently false assertions like this:

According to liberation theology, progress for the poor is not likely to ensue from development approaches which are based on a "liberal" view of poverty. Liberal views place the problem with the poor themselves: these people are backward and reject the technological fruits of modernity.

And what of the liberals then? I doubt they would agree with this assessment. Similarly, his discussion of the inherent weaknesses of for-profit healthcare (which I am sympathetic to) is full of very, very bad economics, and derision for "profit" without even defining terms. What is profit here? Accounting profit or economic profit? If economic, a Marxist profit or a neoclassical one? If one holds to the labor theory of value, sure, I can see the issue, but if one does not?

Throughout the book, Farmer makes a lot of un-verified propositions and unexplained assumptions (e.g., the homeless poor are not only equally deserving of medical care, but more deserving than the median citizen), presenting them as factually true when in fact the are the subjects of considerable disagreement and debate. That's cool, I guess, it's his book, but ultimately it is self-serving – people who like this sort of thing will find this is the sort of thing that they like – but doesn't further the conversation, instead talking past the counter-arguments, and it doesn't move me to act.

[Ron Willoughby · Rating 4 out of 5]

It's hard to give any kind of meaningful review of this book. It doesn't fall into a nice, clean category or two. These are the intelligent, cogent, often pained, frustration-filled essays of a brilliant man who may one day be recognized as one of the greatest humanitarians of my generation. (He was born in '59. I was born in '64. So, I claim him for my generation.) These essays were mostly written in '98 - 2000. He makes some profound statements regarding the responsibility to protect coupled with a Theology of Liberation. He lived for 22 years more after these expressions of sadness, righteous indignation and rapier insight. He died in Rwanda in 2022. He was 62. He packed so much life, healing and concern for others in those 3 score and 2 years. I am moved by this work but saddened, I think, by the sense of hopelessness that seemed to be creeping into his words. It is a logically argued, principled work. It stands as a testament to the 'midway point' of his work, life and calling.

[Joseph · Rating 5 out of 5]

A very good book, a very sobering book, a very frustrating book, a very important book.

[Cassidy · Rating 5 out of 5]

Simply another stroke of genius from Dr. Paul. Each chapter kept getting juicier, and each time you think he won’t address the deeper issues of certain topics (re: his view on western/American approaches to social and economic inequalities, uncovering the truth of market-driven medicine) he just keeps spilling the tea 🍵

My one and only critique is that I wish it could be written in a way that is slightly more accessible to people without a global health and development background, because this is simply a goldmine to both inspire and spark debate about the social justice approach to universal health coverage.

[Eric Miller · Rating 4 out of 5]

Paul Farmer's professional titles are impressive, but at the core he is a physician-anthropologist serving the world's poorest people. He has tirelessly struggled to provide the absolute best healthcare to people in tremendous need, despite critiques that his approach is not cost-effective or sustainable. Pathologies of Power is Farmer's impassioned critique of the rampant inequality and human rights violations in the world today. It is his desperate plea for us to wake up and recognize that it is not only disgraceful that so many people have so little--it is totally unethical.

Farmer has something to say, and in this book he says it without reservations. He demands that we start doing some serious soul-searching, asking ourselves why, in this age of iPhones and $100 billionaires, there are still billions of people living lives of miserable poverty, dying of starvation, political violence, or treatable infectious diseases. The essence of Farmer's argument is that social and economic rights (e.g. food, water, shelter, healthcare, education) should be recognized as essential human rights, with at least as much importance as political and civil rights.

By essential human rights, we are talking about the rights of every human being on the planet. Farmer shows how entrenched systems of political and economic power create a kind of "structural violence" against the poor, keeping them in squalor and predisposing them to dramatically increased risks of physical violence and death from treatable diseases. According to Farmer, there have been three major approaches to solving this problem: charity, development, and social justice. While all approaches have their merits, Farmer argues that only social justice reaches the core of the problem: that it is unacceptable for any human being to not have access to high-quality healthcare.

In deciding courses of action, Farmer defiantly eschews all notions of "cost-effectiveness" or "sustainability." While these notions seem rational in the short term, Farmer argues that they create an unethical double standard. A rich man in Boston with HIV gets the best antiretroviral drugs on the market, while the dying masses in Haiti or Africa get "cost-effective" handouts. Farmer cites the liberation theology movement as a theoretical and moral foundation for his work. He writes that the struggle for human rights (including economic and social rights) is best seen as a struggle for liberation of the poor from the grip of structural violence, rather than as a biproduct of charity or development.

Many people view Farmer as an unrealistically utopian thinker, and Farmer himself does not claim that his free clinic in Haiti is "sustainable" or repeatable the world over. I only gave the book 4/5 stars, because I found it to be excessively long-winded and somewhat repetitive in parts. Nevertheless, his work represents an unflinching struggle for human rights, using his skills as a physician to treat hundreds of thousands of poor Haitians who otherwise would have died "stupid deaths" of political violence or treatable diseases. It is our responsibility, Farmer says, to end structural violence in our world. Anything less is shameful.

[Tara · Rating 3 out of 5]

Farmer stands emphatically on the side of the destitute, marginalized, and usually overlooked. His case studies exemplify the fate of millions of "nobodies" - the silent majority of the world's population who have no or inadequate heath care.

Reading a lot of economics -- and even a lot of politics inspired by economics -- and then reading Farmer, I'm struck by how arid the former sounds in contrast to the latter. A cold calculus might explain to us why we should treat the poor well. Maybe we can justify redistribution to the poor because their utility from one marginal dollar is higher than that for a wealthy person. Or maybe we should aim to stop multi-drug resistant tuberculosis in prisons because those prisoners will go out into the outside world and infect the wealthy. Farmer cuts through that with this main argument: "We should help the poor because they are poor, and it is our obligation as humans to serve the least fortunate and support the basic human right that is health care."

This is not a hopeful book. It's very, very bitter. Most of Farmer's stories are his personal experiences, and he angrily ticks off case after case where what initially looks like a senseless, random death is seen to be a symptom of a deeper systemic problem. Farmer argues that entrenched systems of political and economic power create a kind of "structural violence" against the poor, keeping them in squalor and predisposing them to dramatically increased risks of physical violence and death from treatable diseases. According to Farmer, there have been three major approaches to solving the problem of structural violence: charity, development, and social justice. While all approaches have their merits, Farmer argues that only social justice reaches the core of the problem: that it is unacceptable for any human being to not have access to high-quality healthcare.

Overall this book had powerful, informative stories with emotional force behind them, but that emotional force causes Farmer to repeat himself many times and offer few actual solutions to the problems he details. Read it if you're particularly interested in the subject, but I wouldn't recommend it.

[Kara · Rating 4 out of 5]

I was first introduced to Paul Farmer when I read Tracy Kidder's Mountains Beyond Mountains this past summer. While Kidder's book dwells on Farmer's life specifically, this book — by Farmer himself — takes a much broader view and outlines the doctor's convictions on poverty, health, human rights, international aid and policies, and how they all come together to create structural violence that keeps the poor ill and oppressed.

Farmer assumes a certain level of familiarity with his concepts, from tuberculosis treatment to liberation theology, and I was grateful that I had read Kidder's book first, as Kidder assumes more of a neophyte audience than Farmer does. Of course, someone with no exposure to health or human rights issues among the poor is unlikely to randomly pick up this book in the first place, so I doubt that will be a problem.

Farmer is the first to admit that he approaches these issues from the limited perspective of a physician-anthropologist who has worked closely with the poor in specific communities such as rural Haiti or Russian penal colonies. However, it is hard to argue with his passionate claims, as he actually witnesses this structural violence firsthand, while the policymakers who take the so-called "broad" or "global" view are holed up in offices far from the poor who are affected (often fatally) by their decisions.

Much of this book's text was written in the late 90s, with postscripts providing updates in the mid-2000s. I would be interested in seeing an even more updated version of this book that explores how more recent events — such as the horrific 2010 earthquake in Haiti — further contribute to structural violence.

[Mica Verendia · Rating 4 out of 5]

This was assigned to me in my Development Anthropology class years ago, but I'm re-reading it, because I probably missed a lot of things that my frazzled, school-tasked brain disregarded because I had to write a specific paper on it. So far, I am right. Truly eye opening, and despite the fact that it's a more scholarly read, it's an easy read and totally engrossing, that is, if you're a public health nerd like I am.

[Amber · Rating 4 out of 5]

This book used the level (or lack) of health care in poor communities around the world to demonstrate the structural violence and injustice inherent in neoliberalism. Doctor Farmer approaches the subject with the research and facts of a clinical practitioner, but through his empathy and anger he is able to call into question the real commitment to human rights and justice around the world. For some reason this book left me hopeful.

[Elsie · Rating 5 out of 5]

I was enthralled with Paul Farmer's work as shared in Tracy Kidder's book "Mountains Beyond Mountains". I finished this book "Pathologies of Power" just before listening to him and Dr. Jim Kim address the American Anthropological Society in DC and was not disappointed. In fact, I was very much impressed. I watched the documentary about parts of his work "Bending the Arc". We each need to understand how our "first world choices" affect others around the world and in our own communities.

[Madeleine · Rating 4 out of 5]

What do I even say about this book? Paul Farmer's my hero. These essays are amazing. If I ever write a book (ha), I want it to be this smart and this angry and this beautiful.

...see, I have only trite things to say about this. That's how good it is. So read it.

[Mirwais]

i will learn the way of treating patients

[Lisa · Rating 5 out of 5]

This is the first book of Farmer that I read. It transformed the way that I viewed the world: it introduced me to the idea of liberation theology and the writing of Eduardo Galeano.

[Aya · Rating 4 out of 5]

Its an interesting read, that can be an eye opener for some people