Paul Farmer

Health, Human Rights, and the New War on the Poor

Pathologies of Power

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How do we, as the lingo would have it, “process” such abominable contiguity? Our best hope, it sometimes seems, is oblivion. Let the world’s endless jeremiad be blotted out by action films and other entertainments, sport-utility vehicles, high irony, identity politics that erase the world’s poor, or struggles for personal advancement within this or that institution. 

Although many global health indicators show significant improvement, we still have endless work to do before we can claim to have made the slightest headway in ensuring the highest possible level of health for all. In fact, several studies suggest that inequalities in health outcomes are growing in many places.65 From the human rights perspective advanced in this book, this growing outcome gap constitutes both a human rights violation and a means of tracking the efficacy of our interventions. That is, reduction of the outcome gap is the goal of our pragmatic solidarity with the destitute sick.

What I am suggesting is that ethical codes and review boards are not always helpful, to put it politely. They often share an unacknowledged agreement that in fact all humans are not created equal and that this inequality accounts for both differential distribution of disease and differential standards of care.

What do we know about epidemics of MDRTB in U.S. prisons? To begin, it is clear that several of what are termed “nosocomial outbreaks” began not in hospitals but in prisons. In the largest U.S. outbreak, which began in New York City in 1989, fully 80 percent of all index cases could be traced to jails and prisons.

We have a lot to offer right now. In Haiti and Peru and Chiapas, we have found that it is often less a question of “development” and more one of redistribution of goods and services, of simply sharing the fruits of science and technology. 

Those who believe that charity is the answer to the world’s problems often have a tendency— sometimes striking, sometimes subtle, and surely lurking in all of us— to regard those needing charity as intrinsically inferior. This is different from regarding the poor as powerless or impoverished because of historical processes and events (slavery, say, or unjust economic policies propped up by powerful parties). There is an enormous difference between seeing people as the victims of innate shortcomings and seeing them as the victims of structural violence. Indeed, it is likely that the struggle for rights is undermined whenever the history of unequal chances, and of oppression, is erased or distorted.

For me, applying an option for the poor has never implied advancing a particular strategy for a national economy. It does not imply preferring one form of development, or social system, over another—although someeconomicsystemsare patently more pathogenic than others and should be denounced as such by physicians. […] Whether youare sitting in a clinic in rural Haiti, and thus a witness to stupid deaths from infection, or sitting in an emergency room in a U.S. city, and thus the provider of first resort for forty million uninsured, you must acknowledge that the commodification of medicine invariably punishes the vulnerable.

It also responded to patients’ appeals for nutritional assistance. The patients argued, often with some vehemence and always with eloquence, that to give medicines without food was tantamount to lave men, siye atè (washing one’s hands and then wiping them dry in the dirt).

When children living in poverty die of measles, gastroenteritis, and malnutrition, and yet no party is judged guilty of a human rights violation, liberation theology finds fault with the entire notion of human rights as defined within liberal democracies.

‘I came to San Cristóbal to convert the poor,’ he would later say, ‘but they ended up converting me.’”

Mexico is not purely a poor country: rather, it has become one of the world’s largest producers of new billionaires—mainly as aconsequence of upwardredistribution.35 The declining fortunes of the indigenous peoples led to work migration—people going to Cancún, for example, in search of work building condos and hotels—and a growing resentment of longstanding and ever more visible inequalities.

The World Health Organization released an assessment of the health care systems of all member states. The evaluation relied on several indicators, including quality of health services; overall level of health; health disparities; and the nature of health system financing. Of all 191 member states, the United States spent the highest portion of its gross domestic product (GDP) on health—but ranked only thirty-seventh in terms of overall performance. Tiny Cuba, spending a smaller portion of its GDP, was ranked at roughly the same level as the United States and was one of the four highest-ranked countries in Latin America. (It is notable that the other countries with high indicators are either industrialized or have long histories of social-democratic government and universal health care.) As for “fairest mechanism of health system financing,” Cuba was the number one nation in Latin America; the United States did not even figure in the top fifty in this category.59 Clearly, it has been hard to see this from within the United States, where there is an embargo on honest assessment of Cuba’s health programs.

Cuba began its HIV screening program early, compared to many other countries. Cuba’s policies to protect its population from transfusion-associated HIV compare favorably to almost any other country’s, including those of (notoriously) France and (less notoriously) the United States.44 In 1983, the etiologic agent of AIDS had not been identified, but blood-borne infection was suspected. Cuba therefore banned the importation of factor VIII and other hemo-derivatives, and the Ministry of Public Health ordered the destruction of twenty thousand units of blood product. As of December 31, 2000, Cuba continued to have the lowest HIV incidence in the hemisphere and has registered only ten cases of transfusion-associated HIV—only two of those among Cuba’s hemophiliacs.

The World Health Organization now acknowledges that poverty is the world’s greatest killer: “Poverty wields its destructive influence at every stage of human life, from the moment of conception to the grave. It conspires with the most deadly and painful diseases to bring a wretched existence to all those who suffer from it.”50 Today, the world’s poor are the chief victims of structural violence— a violence that has thus far defied the analysis of many who seek to understand the nature and distribution of extreme suffering. Why might this be so? One answer is that the poor are not only more likely to suffer; they are also less likely to have their suffering noticed, as Chilean theologian Pablo Richard, noting the fall of the Berlin Wall, has warned: “We are aware that another gigantic wall is being constructed in the Third World, to hide the reality of the poor majorities. A wall between the rich and poor is being built, so that poverty does not annoy the powerful and the poor are obliged to die in the silence of history.”

Women are at risk for HIV not because they are African-American or speak Spanish; women are at risk because poverty is the primary and determining condition of their lives.

For underneath this silence lies the pent-up anger born of innumerable small indignities, and of great and irremediable ones. Underneath this silence lie the endless jeremiads of the suffering sick. Structural violence generates bitter recrimination, whether it is heard or not. And given that residents of the barrio and the cities and neighborhoods like it are those who endure most of the world’s misery, they are precisely those most likely to have a “vocabulary to explain a degree of pain, its position or its nature.”

For surely we have learned that the right to vote, for example, has not protected the poor from dying premature deaths, caused as often as not by readily treatable pathogens. The “nobodies” discussed by Eduardo Galeano are the victims of structural violence, and a physician working in post-Duvalier Haiti—or postapartheid South Africa—would necessarily want to know why structural violence takes more and younger lives than ever before. In short, civil rights cannot really be defended if social and economic rights are not.

One is reminded of the old joke: What is the definition of a liberal? Someone who believes all the bad things that happen in the world stem from accidents.

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

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