Paul Farmer

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

Pathologies of Power

nhu ⋆𐙚₊˚⊹

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.

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.

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.”

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.

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.”

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 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.

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.

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

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.

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