Hilfiker: Pathologies of Power

But why should this be considered remarkable? Farmer and his colleagues are hardly pioneering new treatment regimens. Their “Directly Observed Treatment” (DOT)—in which a member of the health care team actually observes patients taking their medications—is well known from TB treatment. Farmer’s use of trained community health workers to do most of the continuing care and follow up is standard practice for those working in poor areas of the world. HAART has been well documented to stop the progression of disease in many patients and restore them to a relatively normal life.

What makes the project remarkable is that the poorest people in the West are receiving the same treatment that is available to the rest of the world. Simple justice, it seems, is remarkable.

Living in an Unjust World

How can we come to terms with … the most basic privation from which human beings can suffer? Do we see it simply as a human predicament—an inescapable result of the frailty of our existence? That would be correct had these sufferings been really inescapable, but they are far from that. Preventable diseases can indeed be prevented, curable ailments can certainly be cured, and controllable maladies call out for control. … [W]e have to look for a better comprehension of the social causes of horror and also of our tolerance of societal abominations. (p xii)

The world’s economic, social, political, and military order confers affluence upon a minority of us, poverty on most, and penury upon a good billion. This poverty and penury are not relative terms but absolute conditions that, for instance, kill 25,000 children a day, consign millions to death by AIDS, and make the median age at death in sub-Saharan Africa five years. What does it mean for health care professionals and medical researchers that millions of people suffer and die every year from utterly preventable deaths—what the Haitians call “stupid deaths”—while others live in a surfeit that could easily relieve the worst of the suffering? This is a personal question! How do we make moral sense of the economic, political, and social systems that have bestowed upon most of us extraordinary privileges of wealth and power while those very same systems are directly responsible for the suffering and deaths of countless people in our own countries and around the world?

If we allow ourselves to think this far, most of us do not tolerate the glare of these intractable, harsh questions very long and must avert our gaze. It feels too much like beating ourselves up. Eventually, even researchers committed to social justice or practitioners working with the poor feel pressed to change the questions, accept patently false answers, or retreat behind one shield or another. Paul Farmer does not look away but resolutely examines the injustice in an “effort to reveal the ways in which the most basic right—the right to survive—is trampled in an age of great affluence, and [he] argues that the matter should be considered the most pressing one of our times” (p. 6).

Farmer is professor of medical anthropology at Harvard medical school, an infectious disease physician practicing in Boston’s Brigham and Women’s hospital, founder of the international Partners in Health, and an international consultant on TB and AIDS, but he spends a majority of his time caring for patients at a clinic in Cange, a small village on Haiti’s Central Plateau. He is uniquely positioned to explore the fundamental dichotomies of privilege and oppression, of power and powerlessness, of affluence and poverty that threaten our civilization. Pathologies of Power examines the nature of the structural violence that oppresses the world’s majority and the role of government, academia, and the media in rendering that structural violence largely invisible. Farmer exposes the excuses of “limited resources” and “cost-effectiveness” and challenges head-on a theology of the free market that silences the relevant questions. Society’s failure to prevent preventable disease and its unwillingness to treat treatable disease, he suggests, are human rights abuses of the highest order. He indicts medical ethics’ refusal to confront disparities in access to health care as tantamount to erasing the lives of countless people.

I was aware of a strong temptation to turn away from Farmer’s book. There is enough bad news in the press and in one’s own life to dissuade the reader from accompanying Farmer in his explorations. The problems of structural violence and injustice seem overwhelming, insoluble hopeless. Nevertheless, medicine and social science share a commitment to look upon and seek to solve this self-reinforcing tangle. Injustice in an ever-shrinking world will impact each of the possible apocalyptic futures: terrorism, nuclear proliferation, class war, immigration, environmental devastation, and others. Farmer’s description of his work in Haiti, his visits to Chiapas, Mexico, and his extensive consultations within the Russian prison system are painful. His analysis of the structural violence inherent in the systems that benefit us the affluent is difficult. Fortunately, his book is ultimately a work of hope, a clear-eyed look at what is wrong and what must change.

As a physician who has lived and worked in the inner city of Washington DC for twenty years, my experiences resonate deeply with Farmer’s descriptions and analysis. The same systemic forces that claim the lives of Haitian peasants, Mexican campesinos, or Russian prisoners also lead to the suffering and death of people in inner city. Poverty in Washington DC—as in Haiti, Chiapas, or the Russian prison system—is a life-threatening condition. Poverty, the World Health Organization has recognized, is the world’s greatest killer (p. 50).

Structural Violence

Acéphie Joseph was twenty-six when she died of AIDS in Haiti. She acquired the disease in a brief sexual relationship with a soldier when she was nineteen. She couldn’t afford medications or treatment for her disease and left an infant daughter, also infected. Shortly after she died, her father hanged himself. From one point of view, Acéphie died because of “fate” and poor personal choices.

Farmer suggests, however, that any analysis of Acéphie Joseph’s story must be historically deep and geographically broad. One beginning point might be 1956 when Acéphie’s family was forced out of their ancestral home and farmland in a fertile valley because the regime, in cooperation with international aid groups, built a dam that flooded the valley. Uncompensated for their loss, the Josephs were forced onto barren land and into penury. At age 19, Acéphie was courted by a soldier. Although her family knew the soldier was already married, he was one of the few men in the area with a steady income, and the family desperately needed money. Acéphie felt she had no other choice, no other chance to rise out of poverty. The relationship was brief because the soldier became ill shortly thereafter and died. Acéphie hadn’t known he was HIV-positive, but she was already infected. There was no effective medical treatment during the late 1980s, but she wouldn’t have been able to afford it anyway.

Or the story could begin in 1804, when Haiti was established as the world’s first black republic and the United States boycotted it for fifty years and then supported various military dictators who over the years left the country impoverished. Or the story could begin in Africa when Acéphie’s ancestors were rounded up and sold into slavery. The death of Acéphie Joseph will only be understood in its wider context, including the active involvement of the United States and other Northern nations in impoverishing her country over two centuries.

Understanding the geographical and historical context (rather than blaming only fate and/or the poor personal choices of the victim) ultimately implicates us—the beneficiaries of the wider economic and political system—directly in Acéphie’s death. From that point of view, the primary cause of her death is the “structural violence” of the system in which she lived. Structural violence results from social, economic, and political structures that produce poverty, death and enormous suffering.

Structural violence is largely invisible for us who benefit from the current social, economic and political arrangements. The cognitive dissonance between the overwhelming suffering of the poor and our attachment to our own way of life makes turning away and “not seeing” understandable human behavior. “It stands to reason that, as beneficiaries of growing inequality, we don’t like to be reminded of misery and squalor and failure,” Farmer writes (p. 176).

Farmer suggests other reasons for the difficulty in seeing the structural nature of the violence. First, its victims are usually far away (usually geographically and always experientially) and their affliction is lurid, so their suffering becomes “exotic” and difficult to identify with. Second, the overwhelming weight of the suffering crushes our vision. Third, while the nature of the world’s economic and political system ensures that in general money and power flow from the poor and powerless to the wealthy and powerful, the dynamics and distribution of particular suffering are still poorly understood because “one must embed individual biography in the larger matrix of culture, history, and political economy” (p. 41).

The relationships between poverty and disease, for instance, are too often hidden from the public eye. The United States keeps the usual health and mortality statistics by race but not by social class, so the infant mortality for non-Hispanic blacks is known to be 2.3 times greater than for whites and the life expectancy of whites five-and-a-half years greater than for blacks, but there are no statistics for infant mortality or life expectancy among the American poor. The unarticulated implication is the suffering from these disparities has something to do with African-American genetics or “culture” of (about which little could be done) rather than income distribution (which could be modified by political and social choices).

Deep is the fog that keeps structural violence hidden, for the oppression results so often from complex interactions of many specifics that differ from place to place. They are not simple issues; vested interests often obscure them; the usual media don’t report them. Brief descriptions of the structural dimensions of the suffering seem unbelievable, almost paranoid, easily dismissed. More thorough explanation, however, seems too specific and complicated encouraging us to throw up our hands, bemoan the complexity, and move on to something else. Either way we fail to understand.

Multiple Drug-Resistant Tuberculosis in Russian Prisons

But Farmer has committed his life and his resources to the oppressed, which has lifted the fog considerably. The nature of the oppression has become obvious and a response unavoidable. He asks the reader to accompany him into the complexity of one instance of structural violence: an epidemic of Mulitple Drug Resistant TuBerculosis (MDRTB) inside the Russian prison system. It’s a complicated story but the thread is worth following.

Since the demise of the Soviet Union, the collapse of the Russian economy has transformed the penal system into the perfect incubator for MDRTB. Courts are clogged, pre-trail detentions of up to a year (illegal under Russian law) are common, and the prisons are desperately overcrowded and poorly ventilated. In those conditions, of course, tuberculosis (TB) thrives, especially given the rising incidence of AIDS.

TB treatment protocols are complex. They must include multiple drugs given concurrently and consistently, and they must be prolonged: at least nine months and sometimes longer. Drug resistant stains of TB are common. When patients do not respond quickly to treatment, therefore, cultures must be taken and the bacilli tested for resistance. The ineffective drugs must be dropped and much more expensive “second-line” drugs added to the regimen, taking care to observe for resistance in these second-line drugs, too. Once resistant strains do develop in one prisoner, of course, crowded prison conditions lead to the spread of the now drug-resistant disease.

A stopgap measure to slow the epidemic has been the establishment of approximately fifty penal colonies specifically for TB prisoners. Budget cuts have left virtually no money for medications. Farmer visited a TB colony of 909 prisoners with an annual medication budget of just over $2,000. There is no money for MDRTB testing; so all prisoners are treated with the relatively cheap combination of the three primary drugs. Interruptions in the supply of one drug or another are common, leading to treatment with only two or even just one of the drugs; or treatment is sometimes interrupted completely, perfect conditions for development of drug resistance. Even when prisoners do not respond to the treatment and the diagnosis of MDRTB is highly likely, there is little money for testing and even less for the more expensive (and often just unavailable) second-line drugs, so treatment with the now ineffective drugs is continued anyway. Because up to half of the prisoners with active TB in the Russian prison system has MDRTB, new patients acquiring the disease often contract the resistant variety.

The exact dimensions of this MDRTB epidemic are unknown. Russian officials estimate that 10% of Russian prisoners (or 110,000) have TB. Since testing is not done, the prevalence of MDRTB is unknown, but estimates vary from 20% to 50% of the TB population. Even the most conservative figures, therefore, indicate 22,000 cases of MDRTB in the Russian prisons, by far the largest known outbreak in the world. The current inadequate treatment practices only insure its escalation.

Because treatment with the more expensive second-line drugs is rarely available, prisoners either die from the MDRTB while in prison or are discharged into the general population, which has caused a dramatic, three-fold rise in TB and in MDRTB in Russia; increasing international travel spreads the disease widely. The outbreak is confined neither to the Russian prisons nor to geographic Russia. After starting among the poor, this epidemic threatens everyone.

Medically, what should be done is obvious. Decrease the crowding in prisons and increase the ventilation. Test all prisoners for TB and all diagnosed cases for MDRTB. Quarantine all patients with active TB in specially ventilated isolation units and treat them with appropriate drugs for several weeks until they are non-infectious. Continue following all patients until they are free of the disease (nine months or more). Even with adequate resources, of course, this would be a difficult task since many TB drugs have annoying and/or serious side effects that must be continually monitored. Patients find it difficult to continue treatment after they begin feeling well, so they must be continually monitored.

The stumbling block, as always, is resources. A New York outbreak of 1,279 cases of MDRTB from 1991 – 94, of which 80% were traced to prisons and homeless shelters, is estimated to have cost $1 billion in new and renovated facilities, personnel, medical care, and medications. With an outbreak somewhere between twenty and fifty times that size, “the Russian MDRTB is already so widespread that no single country, and certainly not one in the midst of economic turmoil, could ever hope to assume complete financial and technical responsibility for its control” (p. 120).

Unlike Soviet times, Russian prison officials and doctors openly acknowledge the problem and its utmost seriousness. Prison doctors—knowledgeable and competent by Farmer’s expert assessment—know they are not offering proper treatment. They lack fundamental resources.

Although medical resources were also strained during the Soviet era, prison officials contend that they then had enough to do the needed testing and treatment. The MDRTB outbreak is a phenomenon of post-Soviet Russia, the privatization of resources, and the battering of the Russian economy at the hands of unfettered free-market capitalism. Privatization and “health care reform” have led to a massive reduction in public health care expenditures, and the few private, for-profit medical businesses available will not find much profit in treating prisoners or even their families.

A prison sentence in Russia has become for many a death sentence, even those eventually determined innocent.

How have the international health organizations and experts reacted? According to Farmer, the primary response has been to blame either the “antiquated” Russian health care system, the Russian doctors for not following accepted protocols, or the prisoners themselves for noncompliance. The experts, Farmer says, continue to insist that the proper treatment for all tuberculosis in poor countries like Russia is nine months of “directly observed” treatment with the three cheap first-line drugs. Such treatment makes little sense, however, in cases of MDRTB since the bacilli are resistant to the first-line drugs. Russian prison health officials follow the international recommendations (because they have no resources to do anything else), but, as could be predicted, thousands of inmates fail the therapy.

International expert opinion has tended to blame poor treatment outcomes on the hapless TB services, both prison and civilian, or on a lingering “Soviet culture,” rather than on the social and economic conditions that are at the heart of both the epidemic of imprisonment and the epidemic of tuberculosis. Worse still, many international experts continue to insist that the prescription for Russia’s runaway TB epidemic must include only the wise use of first-line drugs—this at a time when fully half of all patients with active disease are sick with strains resistant to isoniazid or streptomycin [two first-line drugs].” (p. 120, italics mine)

Pushing further, Farmer discovers that many international experts don’t believe it is “possible” to treat MDRTB in such circumstances. In rebuttal, Farmer describes successful treatment of MDRTB by his Partners in Health in the slums of Lima, Peru. “Public health officials in Peru and the United States, as well as from the World Health Organization, cautioned that we could not expect good results” (p. 122). Although treatment was certainly expensive, most of the fifty patients in the trial responded and at the end of two years 80% were free of persistent disease, demonstrating that it is possible to treat MDRTB in such difficult circumstances.

The reason frequently given by the international consultants for insisting on simple treatment with first-line drugs for everyone in the Russian prison system is that it would not be “cost effective” to use the more expensive second-line drugs. A treatment course with the former can cost less than $100 while the latter can cost tens of thousands of dollars. The consultants mean that budgets are limited, and it makes more sense to treat everyone with the cheaper regimens than a very limited number of MDRTB patients with the more expensive regimens. Appropriate treatment for all prisoners with MDRTB isn’t possible in a world of “limited resources.”

In fact, we live in a time when resources are less limited than ever before in history, but they are unavailable for the poor. The real problem is not “limited resources” but an unjust distribution of wealth and society’s unwillingness to control the upward flow of money and resources from the powerless to the powerful. “Cost effective” means that the lives of thousands of prisoners are not worth saving. “Limited resources” is nothing more than a euphemism for injustice.

Is it fair for Farmer to blame the international health experts and organizations with limited budgets for the deleterious economic structures of our society? Of course not. But it is fair to insist that they not cover up the reality of the suffering by continuing to insist publicly that treatment with first-line drugs is the recommended treatment for everyone in the Russian prison system. It is fair to insist that they stop declaring patients “untreatable.” It is fair to insist that they provide a translation for their explanation that it’s not “cost effective” to treat people dying to MDRTB, that they remind the public that the issue is actually justice. It is fair to blame the experts for refusing to diagnose an economic and political system that will not treat treatable patients and sentences them to death.

With whatever blend of intention, professional blindness, or ignorance, the response of the international health community to the Russian prison MDRTB epidemic refuses to challenge the morality and adequacy of an unfettered, free-market capitalism. Rather than indicting the injustice of the economic and political order, the international health community supplies cover stories that keep the injustice of (and our responsibility for) the tragedy hidden from the public. Medically nonsensical sound bites conceal lethal structural violence.

Farmer’s work is a major indictment of neoliberalism.

Some justify opposition to the aggressive treatment of MDRTB in developing countries as public health realpolitik, but careful systemic analysis casts doubt on such notions. Although our failure to effectively confront tuberculosis is obvious, the hypothesis that we lack sufficient means to cure all tuberculosis cases, everywhere and regardless of susceptibility patters, is not supported by data. There is plenty of money—even in many poor countries. The degree of accumulated wealth in the world today is altogether unprecedented, but this accumulation has occurred in tandem with growing inequality. (p. 172)

Preferential option for the poor

Neoliberalism—the imposition of the unfettered free market on world economics—is based on a popularized utilitarianism that justifies the suffering of some for the benefit of others. What number of MDRTB prisoners are we willing to let die rather than mount an extensive, expensive international campaign to treat them? What is the acceptable number of the world’s children dying every day from preventable diseases? How many ghetto residents can we educate inadequately, subject to disease, and surround with violence before it becomes unacceptable? Face-to-face with the losers, most of us would find such “cost benefit” analyses morally repugnant.

Farmer suggests an alternative perspective for social analysis: the suffering of the poor. He looks for inspiration to liberation theology’s “preferential option for the poor.” Theologically based on both Hebrew Bible and New Testament, liberation theology arose in South American “base communities” in the experience of poor and oppressed people reading the Gospel texts. They discovered that Judeo-Christian teachings judge the world from the point of view of the “widows, orphans, and aliens,” a perspective on power from the point of view of the oppressed.

Truth … is to be found in the perspective of those who suffer unjust privation. [T]he condition of truth is to allow the suffering to speak. It doesn’t mean that those who suffer have a monopoly on truth, but it means that the condition of truth to merge must be in tune with those who are undergoing social misery—socially induced forms of suffering. (p.153)

As Farmer guides us through AIDS in Haiti, poverty in Chiapas, and the MDRTB epidemic in Russia, vast social forces become visible, arrayed against people who, on first look, seem to have brought their poverty upon themselves. He brings us into those communities and analyzes the structural violence. He also makes us uncomfortable by showing us our responsibility and our many tactics for evading it.

In Farmer’s vision, structural violence threatens the right to life and liberty, even equality before the law. While there is certainly a difference between torture and a slow death from untreated tuberculosis or AIDS, they are both on the same continuum, People’s civil and political rights cannot be protected if their basic rights to food, housing, clothing, education, and health care are not met. Social and economic rights, including health care, must be considered human rights.

When we regard the perpetrators of these crimes [upon the poor] from any comfortable reserve, it is important to recall that with our comfort comes a loss of innocence, since we profit from a social and economic order that promises a body count. That is, surely there are direct and causal relationships between a protected minority enjoying great ease and those billions who go without the bare necessities of food, shelter, potable water, and medical services? Pathologies of power are also symptoms of surfeit—of the excess that I like as much as the next guy. (p. 255)

The United States carries more than its share of these pathologies of power. But beyond the direct US support for oppressive governments around the world, there is the neoliberal organization of the international economy that has dominated for the last several generations through the World Bank and International Monetary Fund and more recently through trade agreements such as the North American Free Trade Association (NAFTA) and the World Trade Organization (WTO) that implicates all the world’s affluent. While the details of how those international organizations and agreements oppress the poor are too complex to describe in this essay, they include demands that poor countries reduce their social budgets (for instance, draconian cuts in spending on education or health care); bans on government protection of domestic manufacture for export; the weakening of unions and other protections for workers; insistence on instantaneous, electronic flows of speculative capital in and out of countries (often destabilizing smaller economies); agreements permitting transnational corporations to sue countries for impeding their pursuit of profit; and so on. This becomes personal when we see through the fog and recognize that we who are affluent benefit from precisely those structures that oppress the poor and that we have the responsibility to repair the damage.

“As a physician who has worked for much of my adult life among the poor of Haiti and the United States,” writes Farmer, “I know that the laws of supply and demand will rarely serve the interest of my patients” (p. 5).

[We] must acknowledge that the commodification of medicine invariably punishes the vulnerable. A truly committed quest for high-quality care for the destitute sick starts from the perspective that health is a fundamental human right. In contrast, commodified medicine invariably begins with the notion that health is a desirable outcome to be attained through the purchase of the right goods and services. Socialized medicine in industrialized countries is no doubt a step up from a situation in which market forces determine who has access to care. But a perspective based in liberation theology highlights the fundamental weakness of this and other strategies of the affluent: if the governments of Scandinavian countries and that of France, for example, then spend a great deal of effort barring noncitizens from access to health care services, they will find few critics within their borders. (Indeed, the social democracies share a mania for border control.) But we will critique them, and bitterly, because access to the fruits of science and medicine should not be determined by passports, but rather by need. The “health care for all” movement in the United States will never be morally robust until it truly means “all.” (pp. 152-3)

The Media

One cannot talk about pathologies of power without examining the role of the sprawling corporate media in obscuring structural violence. Usually, the distortion takes place simply by ignoring and not reporting it, but Farmer also offers us an active example of popular media’s consistent blurring of reality and limiting of our vision. He contrasts media treatment of two government quarantines on the island of Cuba. The first is the US military base at Guantánamo Bay where in the early 1990s a few hundred HIV-positive Haitians fleeing the island by boat were quarantined for up to two years. This was after the US-supported 1991 military coup against the government of the popularly elected Jean Baptiste Aristide. Many Haitians who had resisted the coup fled for their lives. Of those caught by US authorities, the vast majority was forcibly repatriated (illegal under international law). After intervention by human rights organizations, a compromise was reached in which some Haitians were sent to a detention facility at Guantánamo. HIV-positive refugees were quarantined in conditions that were remarkably similar to those experienced recently in the prison camps in Iraq (and, most likely, again in Guantánamo). Refugees were denied legal counsel or hearings, and press coverage was prevented. A US federal judge eventually described some of the conditions:

They live in camps surrounded by razor barbed wire. They tie plastic garbage bags to the sides of the building to keep the rain out. They sleep on cots and hang sheets to create some semblance or privacy. They are guarded by the military and are not permitted to leave the camp, except under military escort. The Haitian detainees have been subjected to pre-dawn military sweeps as they sleep by as many as 400 soldiers dressed in full riot gear. They are confined like prisoners and are subject to detention in the brig without hearing for camp rule infraction. (p. 61)

Yolande Jean, a refugee Farmer interviews at length, describes her detention more graphically:

Camp 7 was a little space on a hill. They put up a tent, but when it rained you got wet. The sun came up and we were baking in it. We slept on the rocks; there were no beds. And each little space was separated by barbed wire. We couldn’t even turn around without being injured by the barbed wire. (p. 62)

She also describes forced Depo-Provera injections (for contraception) by military medics, a clear violation of medical ethics and, again, international law.

These were not criminals, but political refugees fleeing for their lives.

The second place that Farmer visits in Cuba is a sanatorium run by the Cuban government where, for a time, HIV patients were forcibly quarantined. (The forcible quarantine was lifted in 1993 although government surveillance of identified AIDS patients continued.) The sanatorium is “a suburban community of several acres dotted with modern, one- and two-story apartments duplexes surrounded by lush vegetation, palm trees and small gardens” (p. 53). Farmer interviews the medical director and several of the residents there and is impressed by the medical care given the HIV-positive patients and by their living conditions. Acknowledging the involuntary nature of some of the restrictions, such as mandatory testing, Farmer notes that Cuba’s policies have resulted in the lowest incidence of AIDS in the Western hemisphere.

Farmer then examines US press accounts of the two places. The US controlled base at Guantánamo is described in a New York Times article headline as an “Oasis to Haitians,” and other stories in the mainstream US media portrayed it as “a haven for refugees.” A New England Journal of Medicine article states, “That the military physicians worked hard to treat the Haitians at the camp was not in dispute” (p. 62)—an opinion in fact disputed by the HIV-infected Yolande Jean—and goes on to blame “cultural differences” for some of the difficulties at Guantánamo.

The sanatorium run by the Cuban government, however, is described by a Chicago Tribune headline as a “prison” and a Los Angeles Times headline calls it “frightening.” US press criticism of Cuba’s decision to quarantine HIV-positive patients was common. Farmer sums up:

[I]n 1991, on a military base beyond the rule of law, the world’s only remaining superpower simultaneously engaged in and denied officially sanctioned violations of the rights of HIV-positive Haitian refugees. The same newspaper that termed this US military base an “oasis” for Haitians readily printed highly critical assessments of Cuba’s sanatoriums. … The point is that understanding the complexities of AIDS and quarantine requires wading through a swamp of ideology. (pp. 74-75)

The media are not necessarily intentionally deceiving readers and viewers, although in some cases that is also true. The point is that journalists and other media authors, editors and publishers come to their work shaped by the same biases that shape the rest of American and other first-world cultures. They are primarily affluent people living in the country that has provided them that affluence. Without great effort to shed the biased class and cultural lenses they have grown, they will see the world through those lenses. Intentionally or not, reports on the conditions of the poor will be ignored or seriously distorted, and the injustice perpetuated.

What Shall We Do?

Health care can be considered a commodity to be sold, or it can be considered a basic social right. It cannot comfortably be considered both of these at the same time. This, I believe, is the great drama of medicine at the start of this century. And this is the choice before all people of faith and good will in these dangerous times. (p 175)

The enormity of the problems that Farmer observes seems to leave those of us committed to justice for the poor up against a brick wall. How do we—practitioners, activists, and researchers—begin to challenge structural violence if the power of capitalism, the powers of the corporations, the power of the media, the powers of governments and, it seems, most other human sources of power are arrayed on the other side? Once we have made the analysis, what’s the next step?

The health care community has a unique position of power and privilege from which to address these complex issues of structural violence. In the last generation our community has taken on other questions of violence—for instance, gun violence and auto safety—and impacted public policy significantly. We have the potential to reframe the debate about issues of structural violence, especially as they impact health and mortality.

As a first step in dealing with structural violence, Farmer suggests that health and healing become the “symbolic core” of the agenda, tapping into the universal concern for the sick. But in order for our expressed solidarity to become “pragmatic,” it is the provision of health care that must become central to our agenda—not a “cost effective” nor “sustainable” provision of care but a provision of care for the poor that is at least equal to that given the affluent. It will, of course, be no short struggle. Farmer again: “In arguing that health care is a human right, one signs on to a lifetime of work dedicated to erasing double standards for rich and poor” (p. 201).

One initiative must be in the area of research. While the general patterns of disease, illness and death resulting from poverty are clear, further research is needed to elucidate the particular mechanisms that translate injustice into poor health. As mentioned above, we in the United States don’t even have good statistics showing infant mortality or life expectancy differences between socioeconomic classes since most of our data is tabulated by race, an imperfect marker for poverty. Why do the poor have more hypertension, more diabetes, more obesity? Have we adequately linked our research and its results to society’s injustice? As a physician I was startled to read some of Farmer’s research papers because he does with some passion include injustice in the chain of causation.

Medical ethics is another area that must be greatly enlarged in scope. What are now defined in medical, nursing, and other health professions schools as ethical issues? Is the deprivation of the vast segments of the human population from adequate medical care included as an ethical issue for medicine? Does anyone on a hospital ethics consultation team speak to the poverty of a patient hospitalized with a stroke after a lifetime of inadequate treatment of hypertension, pointing out that the doctors and hospital have a responsibility to at least raise their voices publicly for universal care? At one level, we are aware of the glaring reality that this inequality is responsible for differences in health care, illness and death across groups of people. But if medical ethics does not speak out publicly, doesn’t it become “yet another strategy for managing inequality”? (p. 201) In their silence, are even our ethicists accepting the unacknowledged assumption that human beings are not, in fact, created equal? Curricula must aim to place students in face-to-face contact with the oppressed (in such environments as student-run clinics or internships in poor areas) but emphasize that the primary emphasis is on learning from the poor, not simply offering services.

Farmer cautions us, however, about too much research and too much talk (not that most of us are in danger of overindulging quite yet). Ultimately our research and our advocacy must be based in the needs of the poor. When Farmer talks with his patients in Haiti, they don’t speak very often about the need for research or advocacy. What they need is food, shelter, education and health care. There is the very real danger that as we abstract ourselves from the concrete life circumstances of the poor we will misunderstand and misdirect our activities. Because we who will do the research or advocacy work are (largely) not poor, we will too often follow our mistaken assumptions and prejudices about the poor. Accordingly, part of our task in health care is to engage the poor, to be in dialog, to come into relationship and stay in a position to hear their truth. We must begin to include the poor into our practices, in our research, in our deliberations, in our medical education (as educators, not just clinic patients); we must find ways to enter into face-to-face relationships with people who experience the structural violence of the society.

Every day, thousands of people die stupid deaths, utterly preventable deaths. We who accept the benefits of the economic, political and social structures that make such deaths possible have the responsibility to change that situation. Paul Farmer lifts up the moral and spiritual imperative of this effort. He not only refuses to look away from the injustice, he also gives us tools to maintain our gaze long enough to see through it to a pragmatic solidarity—an active solidarity—that can lead us to begin again. Paradoxically, the devastating, often painful critique within Pathologies of Power offers healing for the soul.