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

Once again, Paul Farmer proves himself a modern-day prophet. Repeatedly, he goes beyond what would be expected of such a multifaceted physician, anthropologist, and relief-worker. He speaks truth to power with all the fury expected of the contemporary realist and with all the conviction necessary for the idealist. Modern medicine, increasingly driven by destructive market forces, needs more prophetic voices. Farmer's is likely the most difficult to avoid.

Pathologies of Power: Health, Human Rights and the New War on the Poor is the latest in a series of books, each equally disturbing and compelling, that Farmer has published in the last decade. The first, AIDS and Accusation: Haiti and the Geography of Blame (1992), chronicles Farmer's first decade of health work in Haiti, brilliantly describes the initial stages of central Haiti's attempts to make sense of the advent of AIDS, and painstakingly documents the sinister effects of U.S. actions in Haiti. A more recent book, Infections and Inequalities:The Modern Plagues (1999), is a collection of essays analyzing the linkages between global inequality—based on economic class, ethnicity, and gender—and infectious diseases. Pathologies ofPower is another compilation of essays, the latest distillation of Farmer's dissection of the nexus of sickness and social injustice. In different ways in each book, 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.

In Pathologies of Power, Farmer manages to critically analyze U.S. foreign policy, describe the harm brought by the international spread of market rule, scrutinize insidious relationships between disease and social injustice, condemn multiple reigning concepts in the field of international health, and call for a re-examination of contemporary models in both medical ethics and human rights. The first half of the book utilizes case studies observed firsthand by Farmer to show that, time and again, the sicknesses of those who are poor and marginalized are an embodiment of structural violence. In the second half of the book, Farmer offers vital reforming alternatives to the fields of medical ethics and human rights.

Central to Farmer's analysis is the concept of structural violence, a term coined by Johan Galtung to indicate that the unequal structuring of our society harms people, particularly those who are poor. Indeed, the work of many contemporary social epidemiologists and medical social scientists shows that health disparities are determined primarily by inequalities among social economic classes, ethnicities, genders, sexualities, etc. Farmer is one of the most insistent and important voices arguing that structural violence is a primary determinant of both human rights violations and disease. In the present volume, he states that "rights violations are . . . symptoms of deeper pathologies of power and are linked intimately to the social conditions that so often determine who will suffer abuse and who will be shielded from harm" (7). Later, he argues that "suffering is 'structured' by historically given (and often economically driven) processes and forces that conspire . . . to constrain agency" (40). Agency, another term from social science theory, indicates the ability for a human being to determine the specifics of her or his existence through the practice of choice. Farmer shows how social inequalities erode the ability of those who are poor and marginalized to determine their own future, giving examples of structural violence determining human rights abuses and disease from locations as diverse as Haiti, Mexico, and Russia.

These analyses are among the most important for human rights workers and medical professionals to grasp and to act upon. Farmer spends a fair amount of time lamenting the fact that each year millions of people around the world die preventable deaths. Those who are poor die for lack of access to medical care: "In an age of explosive development in the realm of medical technology, it is unnerving to find that the discoveries of Salk, Sabin, and even Pasteur remain...