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BOOK REVIEW

Beyond the Law

Eric Stover

Pathologies of Power: Health, Human Rights, and the New War on the Poor. Paul Farmer. xxiv + 402 pp. University of California Press, 2003. $27.50.

Why, in an age of scientific advancement and economic affluence, are so many of the world's poor deprived of access to health care? This is the central question Paul Farmer, codirector of Harvard's Program in Infectious Disease and Social Change, poses in his thoughtful and provocative book Pathologies of Power: Health, Human Rights, and the New War on the Poor.

Paul FarmerClick to Enlarge Image

Farmer, who is both a physician and an anthropologist, tells us that the ultimate culprit is neoliberalism, "the ideology that advocates the dominance of a competition-driven market model," a doctrine that views individuals as "autonomous, rational producers and consumers whose decisions are motivated primarily by economic or material concerns." Neoliberal policies, he argues, leave behind the powerless, the destitute and the truly disadvantaged, trampling on their most basic human right—the right to survive—in the quest for greater prosperity and affluence among the influential classes. Stark inequities exist: According to the 1996 annual report of the United Nations Development Program, by 1995 the total wealth of the top 358 "global billionaires" equaled the combined income of 2.3 billion of the poorest people in the world. We find ourselves at a crossroads: Will we stockpile the fruits of medical and scientific advances for some and deny them to others? Or will we search for more equitable and just ways to provide health care for all?

Farmer, an indefatigable optimist, believes that in this era of globalization, it is possible to build a more just and equitable world, but only if one works in "pragmatic solidarity" with the world's poor. To this end, he proposes that the human rights movement make a "paradigm shift" away from its current, narrow, legalistic focus on civil and political rights to a concentration on social and economic rights broadly conceived through an analysis of power and social inequality. At the vanguard of this struggle should be health professionals, who along with sociologists must create a new research agenda for human rights. It should be based not solely on the narrow question of "whether an event or process violates an existing legal rule" but on "whether that event or process has ill effects on a patient or population" and, if so, what should be done to rectify the situation. Why health professionals? "The esteem in which public health and medicine are held," Farmer tells us, "affords us openings . . . enjoyed by few other professionals." To illustrate this, he describes how his own organization, Partners for Health, which consists of only a handful of physicians, has become an influential model in the global race to bring antiretroviral therapy to victims of AIDS worldwide.

The first four chapters of Pathologies of Power are eyewitness accounts in which Farmer describes his own experiences in Haiti, Latin America and Russia. In the five analytic essays that make up the remainder of the book, he draws on those experiences to critique "liberal" views of human rights. Seventy-four pages of endnotes and a 45-page bibliography round out the text.

In his most poignant case study, Farmer recounts how he and several colleagues used their "space of privilege" as doctors to gain access to Russian prisons in 1998 to examine detainees infected with tuberculosis, a completely curable disease and the leading cause of death in young adults in much of the world. "We went," he writes, "as TB specialists, with the expectation that a visiting group of doctors might be able to do more for the rights of these prisoners than a delegation from a conventional human rights organization."

A growing chorus of human rights activists and others were calling for massive reforms of Russia's overcrowded and abuse-ridden prison system. Some were advocating an amnesty for up to 100,000 prisoners, a substantial number of whom were likely to have active tuberculosis. A prominent jurist from Poland had taken prison officials to task for allowing 10,000 prisoners to starve to death the preceding year. Yet Farmer and his colleagues found the situation was far more complex and troubling than those critics seemed to realize. Although malnutrition was a problem, the leading cause of death was multidrug-resistant tuberculosis (MDRTB), not starvation. Largely hidden from view, MDRTB had developed into a deadly epidemic claiming thousands of lives each year and was spreading at a rapid rate from prisons to the general population. Left untreated, each patient could in turn infect a dozen or more new contacts each year.

Farmer told the prison authorities that the only way to stop transmission of MDRTB was to treat patients with a costly and time-consuming regimen of second-line medicines. His admonitions fell on deaf ears: Russia's prison system could not afford the drugs, nor were international donors, including the World Bank, willing to fund their use. The "recurrent mantra" he heard was that "the drugs were too expensive to be cost-effective." In his view, by responding in this way the international community was fanning the fires of this highly infectious disease, and he feared that in the long run its spread could prove disastrous far beyond Russia's borders.

Farmer uses MDRTB in Russian prisons as an example of a complex human rights problem that requires the application not of the law but of epidemiology, clinical medicine and sociology. Passing more legislation to protect the political and civil rights of prisoners is not the answer: What is needed is an honest investigation of why second-line tuberculosis drugs, long off patent, remain prohibitively expensive.

Human rights advocates who dismiss social and economic rights, including the right to health care and the right to share in the benefits of scientific advancements, as too "soft" and unenforceable will, I suspect, fault Farmer for aiming his slings and arrows at economic polices far removed from the scene of the crime. After all, who is ultimately responsible (and should therefore be held accountable) for the unchecked spread of MDRTB in Russian prisons? Is it really the architects of neoliberal policies in far-off Washington, D.C., New York and Geneva, for failing to put people before profits by keeping the price of lifesaving drugs so exorbitantly high? Or is it the Russian authorities, for overcrowding their prisons? Or the Russian courts, for failing to process the detainees in a speedy manner and thus leaving them languishing in overcrowded and disease-ridden detention cells?

But to dismiss Farmer's argument out-of-hand would be myopic. We live, as never before, in an interdependent world where international markets and economic policies can and do bear on the lives of the poor, often brutally. Exposing how that process works through methodical research may not put many offenders behind bars, but it could go a long way toward explaining why our world is rife with so many seemingly intractable social and economic inequalities. In the long run, such investigative endeavors probably will actually lead to an accounting of sorts and, more importantly, to change, although this transformation may take time and perseverance.

For an example of how improvements can be brought about, one need look no further than the International Campaign to Ban Landmines (ICBL). First started as a purely research endeavor in the early 1990s by a handful of health professionals and human rights activists, the ICBL traced the production and flow of antipersonnel mines from the developed world to impoverished war-ravaged countries such as Afghanistan, Cambodia and Angola. The organization also published social epidemiological articles in peer-reviewed medical journals, offering irrefutable evidence of the devastating medical and social consequences of mines on victims and their communities. By 1997, with more than a thousand nongovernmental organizations as members, the ICBL had persuaded the governments of 121 countries to declare a moratorium on the production and sale of antipersonnel mines, a feat that earned it that year's Nobel Peace Prize. Farmer, with his talent and tenacity, could inspire a similar victim-based campaign, one that aims to expose the roots of health inequality worldwide and bring the fruits of science and public health to the world's poorest communities.


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