Journeys toward the Splendid City

Pathologies of Power: Health, Human Rights and the New War on the Poor, by Paul Farmer (Berkeley: University of California Press, 2003) 402 pages.

Paul Farmer's latest book, Pathologies of Power: Health, Human Rights and the New War on the Poor, is both a sweepingly ambitious and an intensely personal book. It is ambitious because Farmer—a distinguished physician-scholar who has for years worked with his group, Partners in Health (Partners), treating those he calls the "destitute sick" in Haiti and elsewhere—tackles fundamental questions about how we assimilate on both a personal and a social level the presence of monstrous suffering and privation in a world that also contains obscene levels of opulence and waste. Although it is based on—and in some ways is about—Farmer's experiences working in the developing world, this book is really written for an audience from "the First World university, researchers and health care professionals, students and others lucky enough to be among the winners in the global era[,]"¹ and asks the reader to think about how we can locate the suffering and misery of the many on the same political map as our privileges in order to identify the actors, structures and processes that connect the two in ways that many would prefer not to acknowledge. As Farmer writes, "the drama, the tragedy, of the destitute sick concerns not only physicians and scholars who work among the poor but all who profess even a passing interest in human rights. It's not much of a stretch to argue that anyone who wishes to be considered humane has ample cause to consider what it means to be sick and poor in the era of globalization and scientific advancement."²

Pathologies of Power is also a very personal book, personal because of the many individual stories it recounts and personal because it provides an intimate glimpse into Farmer's emotional reactions as well as his intellectual views. The book is divided into two parts; the first dedicated to what Farmer calls "bearing witness"—his experiences and interpretations of a series of historical events and processes—and the second to proposing new frameworks for understanding the connections between human rights and health. Chapters 1-4 describe Farmer's reflections on: several events during the decades of political violence in Haiti, where Farmer has run a clinic for many years; the detention of HIV-positive Haitian refugees in Guantánamo and a comparison of their conditions with the treatment of HIV-positive individuals by the Cuban government; some of the events and conditions surrounding the uprising by the Zapatista Army for National Liberation (EZLN, according to its acronym in Spanish) in the southern Mexican state of Chiapas; and the growth of multi-drug resistant tuberculosis (MDRTB) from the shantytowns of Lima, Peru to, in particular, the prisons of Russia. Chapters 5-9 revisit many of the themes brought out in the first part of the book, but place them in larger theoretical frameworks and Farmer makes bold proposals for the direction of medical ethics, public health research and practice, and the health and human rights movement.

If we are to take advantage of this important contribution by one of the leading voices in "health and human rights," Pathologies of Power should inspire introspection on the part of all of us who are engaged in medicine, public health research and practice, and human rights to open a far-reaching debate that might invigorate our analyses—and our actions—to address the health and rights effects of the overwhelming concentration of wealth and power in certain countries and institutions. In the Introduction, Farmer writes: "The central thesis of this book is that human rights abuses are best understood (that is, most accurately and comprehensively grasped) from the point of view of the poor. This . . . is a relatively novel exercise in the human rights community. In no arena is it more needed than in that of health and...