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

I was once lucky enough to meet and correspond with Dr Roy Selby (1930-2002), a retired neurosurgeon from Texarkana, Texas. In the 1960s Dr Selby spent seven years in Malaysia, where he built the country's first hospital for neurosurgery. He wrote in one of his last letters: “I discussed with the US ambassador at the time the possibility of the Dept of State providing aid to establish a new medical school, utilising Malaysian personnel. He said something like, `Hell, if we do it we'll do the whole thing.' That is how our government destroys so many overseas ventures—not supporting or [not] allowing the local people to run things. This is another form of aggression.”

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Paul Farmer

University of California Press, £18.95/$27.50, pp 402 ISBN 0 520 23550 9

Rating: ★★★

Dr Selby would certainly have enjoyed this book by Paul Farmer, a professor of medical anthropology at Harvard Medical School and founding director of Partners in Health, a non-governmental organisation “created to remediate inequalities in access to modern health care.” Farmer and his colleagues set up a clinic in rural Haiti. Much of the book is based on Farmer's first hand experience of what he calls a “structural violence and its products—including racism, addiction, lack of insurance, lack of employment, lack of stable housing, domestic violence.” He never provides a clear definition of his concept of structural violence, which is synonymous with “inegalitarian social structures.” Rather he gives numerous examples of when people become sick because they are poor.

Some of these are taken from overcrowded Russian prisons, where Farmer worked as a consultant on a project—funded by the financier and philanthropist George Soros—to control tuberculosis epidemics. It is estimated that a quarter of prisoners in Russia who have tuberculosis have multidrug-resistant tuberculosis. However, Farmer found that in Russia's prisons all patients with multidrug-resistant tuberculosis “were receiving a wholly ineffective treatment on the ground of cost-effectiveness.” He blames “those influential in shaping international health policy, including experts from the World Bank,” who resisted the use of second-line drugs, those necessary to tackle multidrug-resistant tuberculosis, because of their high cost.

Several years ago I interviewed Alexander Goldfarb (then an executive director of the Soros-funded tuberculosis programme for Russia) for our national medical periodical. Goldfarb said that the treatment for one case of multidrug-resistant tuberculosis cost $230 (£136; €195), compared to $50 (£30; €42) for a case of ordinary tuberculosis. The system simply does not have the resources to solve the problem. But this is exactly the point of Farmer's critique: why are these drugs, so long off patent, so expensive? He writes, “Thus has the notion of cost-effectiveness become one of the chief means by which we manage (and perpetuate) modern inequality.”

If the first part of Pathologies of Power relies on eyewitness accounts and author's interviews, the second part is a series of essays on “one physician's perspective on human rights.” Is health care a human right? Farmer's answer is yes. He draws inspiration from the ideas of the German pathologist Rudolf Virchow, who noted that “politics is public health in the most profound sense,” from proponents of liberation theology, and from left wing French intellectuals such as Pierre Bourdieu and Didier Fassin.

According to Farmer, “inequalities of access and outcome constitute the chief drama of modern medicine.” Either health care is a commodity to be sold, or a basic social right. Farmer opts for the latter. He clearly speaks the language of social justice: “Some economic systems are patently more pathogenic than others and should be denounced as such by physicians.” The US healthcare system, with 40 million people uninsured, is surely as pathogenic as health care in Haiti and Peru. On the contrary, Farmer praises Cuba for the promotion of equity. He even appears sympathetic to Cuba's mandatory placing of people with HIV in special quarantine facilities called “sanatoriums.”

Farmer discerns three approaches to addressing the suffering of the destitute sick: charity, development, and social justice. The first two he labels as deeply flawed, preferring to view medicine as social justice work. Farmer's critique of market-based medicine is particularly harsh when he speaks of transnational research. Getting rid of the double standards for the rich and the poor, he says, is the leading ethical question of our times: “Without a social justice component, medical ethics risks yet another strategy for managing inequality.” A new medical ethics should focus on social and economic rights (such as a lack of national health insurance), he says, instead of endless discussions of brain death, organ transplantation, and care at the end of life.

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Farmer: speaking the language of social justice

Credit: GILLES PERESS/MAGNUM PHOTOS

This emotional book is an appeal for a struggle for equity in the field of health and human rights. “If we lived in a utopia,” Farmer says, “simply practising medicine would be enough. But no matter how you slice it, we live in dystopia.” Unfortunately he does not specify how to achieve the utopian ideals which “are the bedrock of human rights.” The revolutionary Ernesto (Che) Guevara, who trained as a doctor, chose the military route to utopia. Is his an example to be followed?