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

In Pathologies of Power: Health, Human Rights, and the New War on the Poor (2005), physician and medical anthropologist Paul Farmer offers a structural analysis of contemporary global health inequalities. His explanation of abiding inequity is twofold. On the one hand, he points to structural violence, the systematic denial of social and economic equity to the world's poor and disenfranchised. On the other, he cites the failure of the human rights project to pursue the social and economic rights without which political rights ring hollow.

Pathologies of Power is an impassioned call for renewing medicine's commitment to social justice. Farmer has written a manifesto for human rights medicine that demands a fundamental re-orientation of the medical and basic sciences towards the needs of the sick and impoverished. He advocates pragmatic solidarity with the oppressed—a solidarity that renders the primary task of medicine to be the alleviation of the ills which those who are suffering say they are suffering from. For the environmental justice community, his conclusion—that what is truly needed is preferential treatment for the poor—will resonate with current debates about climate justice and climate debt. Furthermore, his reminder to health professionals that their job is to serve the poor and vulnerable should remind environmental justice researchers of their commitment to the communities they study.

In Part I, “Bearing Witness,” Farmer uses his experience with Partners in Health to describe the structural violence at work in the AIDS quarantine ward at the American military base in Guantanamo, Cuba; the effect of armed conflict in Chiapas on the health of the indigenous population; and multi-drug resistant tuberculosis in the Russia prison system. In each case study he directs the reader's attention towards how the specific disease pictures of these places results from long-standing social and economic inequalities, many of which are maintained by patterns of international aid.

Part II, “One Physician's Perspective on Human Rights,” is comprised of analytic essays on liberation theology, market-based medicine, and medical ethics, written from the stance of a medical anthropologist. The opening essay describes the relevance of liberation theology to the alleviation of global suffering, and calls for a redistribution of current goods, rather than charity or development. This section is significantly weaker than the first. It is fraught by an ad hoc feel, as Farmer takes aim at a variety of moving targets, from “fraudulently dispassionate academic treatises” to “market forces” to “developmental thinking.”

Pathologies of Power suffers from two fundamental deficits. The first is analytic fragmentation. Farmer cannot seem to decide upon what he wishes to argue, or if he is arguing against public health professionals, the human rights community, academic anthropologists, or development experts. The book's second and more profound problem is philosophical. Farmer argues that current human rights discourse is flawed because it ignores structural violence. He criticizes human rights activists for insisting on the enforcement of political rights, when those rights can only be achieved and maintained after social and economic inequity—structural violence—has been eradicated. Yet Farmer critiques structural violence without naming or calling for the eradication of the structure involved. Indeed, he writes that, “applying an option for the poor has never implied advancing a particular strategy for a national economy … [although] some economic systems are patently more pathogenic than others and should be denounced as such by physicians” (p. 152). This reviewer questioned the value of mere denunciation.

Farmer's text should provide cause to reflect upon the provenance of our analytic tools. The concept of “structural violence” emerged from the discipline of peace and conflict studies, and was furthered by Latin American revolutionary struggles in the 1960s. Absent this political momentum, of what continuing use is this analysis? In fact, without such revolutionary political commitment, “structural violence” becomes impoverished, for those who speak of it must always stop short of advocating a vision for a new world order. This analytic hollow explains why Farmer ultimately argues for the redistribution of the world's existing goods and services without explaining how such redistribution will transpire. Of what good are scholarship and activism to the world's disenfranchised if they remain confined by the discursive and material parameters of the current world order?

Yet, precisely because of its flaws, Pathologies of Power is a critical read for the environmental justice community. For scholars, the book is an inspired reminder of their responsibility towards the communities that they study. Furthermore, the shortcomings of Farmer's analysis offer a rich opportunity for reflecting upon our methodological assumptions. How effective is human rights as a platform for advancing the environmental justice agenda? Can we analyze structural violence without identifying and eradicating its root cause? In the end, disparities in global health or hazardous waste facilities do not reflect a new war on the poor, but rather the current face of a very old one.