Why must the poor be sick? Paul Farmer's exhortations sound familiar, and hopelessly idealistic, until you realize they are backed up by evidence and practical action

Natural History, Feb, 2004 by Jeffrey D. Sachs

Pathologies of Power: Health, Human Rights, and the New War on the Poor by Paul Farmer University of California Press, 2003; $27.50

Paul Farmer is a superb physician, a penetrating anthropologist, and a prophet of social justice. He combines an unflinching moral stance--that the poor deserve health care just as much as the rich do--with scientific expertise and boundless dedication. He has saved the lives of countless destitute patients in Haiti, Peru, and Russia, and he has shown that effective health services, even complex medical regimens, can be put in place in impoverished communities. His accomplishments have forcefully under-cut the flimsy excuses that the rich countries have routinely offered for their inaction, as millions of people die unnecessarily each year in the poor countries. Farmer's moral philosophy, anthropological insights, and medical successes are described in his trenchant and timely new book, Pathologies of Power.

The case studies Farmer presents have three main themes. First, the poor are not the victims of their sins but of their circumstances; instead of sitting in judgment on the sick and dying, the rich countries should be helping to save them. Second, the poor can be successfully treated and cured of disease, even in the most unlikely and impoverished circumstances. Third, the human rights community should be defending the rights of the poor to health, for without the right to health, all other human rights are likely to prove empty. Nothing, Farmer argues, except practical, physical resources--in ample supply throughout the rich world--is keeping the poor world from undergoing a revolution in health.

These arguments are highly persuasive. Even though, at a couple of points, Farmer's emphasis is flawed, his overall arguments are so compelling, in fact, that they are having a significant effect on international health policy.

Farmer's moral stance is grounded in what the liberation theology movement calls a "preferential option for the poor," a principle of Roman Catholic social teaching that enjoins the rich to offer dignity and material support to the poor. Farmer's key epidemiological insight is a powerful, if ironic, twist on this moral dictum: pathogens such as the ones that cause tuberculosis and AIDS also show a preferential option for the poor. What Farmer is saying is that disease, too, follows class lines, tracking down and killing the poor with particular ferocity. Not only do the poor lack access to effective health services, he points out, but they are also systematically forced to live in circumstances that undermine their health and all too frequently claim their lives.

Farmer's many elaborations of this central anthropological insight come into excruciating focus as he tells the personal stories of the indigent. He listens carefully to his patients and thereby uncovers the grim logic that led to their tragic conditions.

A young Haitian woman arrives at his clinic, already near death's door with AIDS. Her short life has been harrowing. For generations her family had Farmed a fertile Haitian valley. Then one day they became refugees in their own country, displaced by a major dam project. Like other refugee families in their settlement, they fell into extreme poverty.

Because she was a young woman, she was harassed by the soldiers who prey on the vulnerable refugee community. In desperation, she entered warily into a sexual liaison with an army captain, who offered some promise of economic stability. But the captain had AIDS, a disease about which she had no knowledge; he died of the disease soon thereafter. The woman tried to save herself and her family by moving to Port-au-Prince and working, for minimal wages, as a housekeeper. Soon enough, she, too, was dying of AIDS.

It is Farmer's deep humanity that draws him beyond what could be just another hopeless clinical case of AIDS, a mere statistic, to the woman's life story and the stories of countless others like her. Such people, as Farmer dramatically illustrates in one example after another, have been caught in the grip of AIDS, not because of sins or misbehavior, but because of poverty--not by accident, but because of the structural fabric of their societies. That realization is filled with far-reaching implications for controlling the transmission of infectious diseases and treating them successfully within a community.

I do have one quibble with Farmer's account, however, that I believe leads his analysis astray, though not his conclusions. His Haitian patients have clearly suffered from what he calls "structural violence." Poverty indeed leaves people vulnerable to violence, not only to the violence of terrible disease but also to the more literal violence perpetrated by other people, who take cruel advantage of the desperate circumstances of the poor. That structural violence, in turn, traps the poor in their predicament, closing the avenues of escape. Farmer claims his term is apt "because such suffering is 'structured' by historically given (and often economically driven) processes and forces that conspire ... to constrain agency."