Despite the remarkable advances in medical knowledge made during the 20th century, the health of the world’s poor has rarely been in such jeopardy. The global AIDS epidemic constitutes the greatest health crisis in history, now encompassing more than 40 million people, the vast majority of whom live in the poorer countries of the South. This crisis has also caused collective introspection and shame within the global public health community over its failure to combat infections which are more easily treatable but still claim millions of lives each year, such as diarrhea, malaria, and tuberculosis.

Almost parallel with the spread of the global HIV epidemic over the last 20 years has been the increasing implementation of structural adjustment programs by the poorer countries of the world at the behest of international lending institutions such as the IMF and World Bank. A central feature of these programs has been decreased spending by governments (termed “austerity measures”), putatively to eliminate wasteful bureaucracy but often resulting in massive cuts in social spending on the health, food, and shelter of their most vulnerable populations. Over the last decade, the compliance of poor countries with the rules of the World Trade Organization has also made it more difficult for them to access cheap, generic drugs for diseases like AIDS. In the light of this ensuing health crisis in the third world, physician-anthropologist Paul Farmer’s new collection of essays Pathologies of Power: Health, Human Rights, and the New War on the Poor could not be more timely.

In the introduction, Farmer raises major deficiencies of the human rights community in an insider’s critique. The first problem, raised often by critics, is the disproportionate struggle of activists to ensure civil and political rights (such as the right to vote or freedom of speech) while largely ignoring social and economic rights, such as the right to food, water, or health. How much does the right to vote matter to a person who is starving? A cynical cartoon published a few years after South Africa’s first democratic elections in 1994 captures this sentiment. While sitting around a fire next to a shack, one man exclaims to another, “How things have changed! A few years ago, I was just a poor, starving, homeless man. Now I’m a poor, starving, homeless man with the vote.”

Despite these arguments, the truth is that enforcing social and economic rights often poses problems that ensuring civil and political rights does not. Opponents argue that these rights require the mobilization of resources on a unique scale—so it is easy to be the activist claiming that a government is violating its citizens’ rights by not providing for the homeless, while it is much harder to be within the bureaucracy that must find money to build those shelters. For this reason, human rights activists stayed silent about social and economic rights for quite a long time: Doctors without Borders and Physicians for Human Rights, two Nobel-prize winning health groups, have only begun raising the issue of universal access to basic medicines over the past few years, for instance.

Farmer’s position on this issue has the legitimacy of years of struggle to provide health care to the poor as a doctor in rural Haiti. Economists who run powerful donor organizations have long favored the market solution for basic needs like health while curtailing economic rights due to “lack of resources.” Farmer highlights the obscenity of this excuse during the wealthiest period of human history. He does not hesitate to chastise activists for failing to confront these “technocrats”:

The hesitation of many in the human rights community to cross the line from a rights activism of pure principles to one involving transfers of money, food, and medicine betrays a failure, I think, to address the urgent needs of the people we are trying to defend. The proponents of harsh market ideologies have never been afraid to put money—and sometimes bullets—behind their minimal and ever-shrinking conception of rights and freedoms. But bullets are increasingly unnecessary when defenders of social and economic rights are silenced by technocrats.
Farmer pushes his critique of the human rights community further by arguing that while activists excel at documenting human rights abuses, they usually neglect to analyze the structural forces that cause these violations to occur. While journalists and activists wrote about human rights violations by the Haitian military in the 80s and 90s, they failed to connect these abuses to US support for the Duvalier dictatorship or the US’s virtual creation of the Haitian military in the early 20th century. Similarly, declining health standards in poor countries are usually not put in the context of economic policies set by powerful lending institutions such as the IMF:

“As international financial institutions and transnational corporations now dwarf the dimensions of most states, the former institutions—and the small number of powerful states that control them—come to hold unfettered sway over the lives of millions. International human rights organizations, accustomed to looking for villains in the upper reaches of bureaucracies of banana republics, also need to turn their gaze back toward the great centers of power in which they reside.”

This passage illustrates Farmer’s central thesis—that the lack of social and economic rights such as the right to health is the outcome of “structural violence” produced by unequal power relations. Hence the title of the book.

Throughout the first half of the book, Farmer uses the narratives of the poor to demonstrate precisely how their illnesses relate to larger structures of power. He shows that the declining health of peasants in Chiapas is not simply an abstract result of poverty but a historical product of Spanish colonialism, underdevelopment by the Mexican state, and, more recently, destruction of livelihoods caused by the NAFTA agreement. A Russian prisoner’s death from multi-drug resistant tuberculosis is not simply a biological phenomenon but a product of the massive decline in social spending that has taken place after the end of the Cold War. He reveals how biased media coverage of US quarantine centers for HIV positive Haitian refugees at Guantanamo Bay allows their victimization at the hands of American authorities to be ignored, while a much more humane quarantine program run by the Cuban government is misportrayed and vilified. The portrait Farmer paints of US policies in Guantanamo is especially relevant and disturbing in light of the current captivity of prisoners of war from Afghanistan and Iraq in this facility.

The second half of the book delves more into human rights theory in light of Farmer’s work in anthropology and medicine. In the best essay of this section, Farmer reveals his own intellectual roots, which derive largely from radical Christian Latin American liberation theologians such as Gustavo Gutierrez. Farmer’s focus on theories of social justice is a pleasant break from standard discussions of Foucault and Derrida common in most current anthropological writings.

Anthropologists may be disappointed that this book lacks ethnographic detail and resembles journalism at times more than ethnography. Similarly, doctors may be disappointed that Farmer does not discuss policy-related issues such as novel tuberculosis control programs, as he did in his prior work, Infections and Inequalities. Yet, Farmer’s writing style is obviously meant to appeal to a much wider audience of public policy makers and activists, in addition to public health specialists. The foreword by Nobel Prize-winning economist Amartya Sen indicates as much.

At times, the book’s second half becomes tiring and discombobulated: not only does Farmer pound in the same themes of “structural violence” and health, but he also often devolves into a great deal of moralizing rhetoric with little substantial argument. The opening of each chapter tends to be overly laden with dramatic quotations. When the reader remembers the seriousness of the subject matter, however, Farmer’s overzealousness seems more permissible.

Farmer’s goal with this work seems to be the creation of a sense of moral outrage by bringing home the distant realities of the poorer majority of our world. He uses this reality to make a compelling call for a new medical ethic:

What is defined, these days, as an ethical issue? End-of-life decisions, medicolegal questions of brain death and organ transplantation, and medical disclosure issues dominate the literature . . . These are quandaries of the fortunate. But in working for the health of the poor, we are faced with a different set of moral issues. Will this patient get any treatment at all? Will her survival be considered less precious than a fourteen-dollar savings in basic medicines? . . . The countless people whose life course is shortened by unequal access to health care are not topics of discussion.

We live in an era of unprecedented wealth and poverty: the income of the world’s 358 richest people equals that of the 2.3 billion poorest. In light of this reality, Farmer’s call to make the way these disparities govern the logic of who lives and dies the central ethical issue in medicine could not be more timely.