Pathologies of Power

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

Paul Farmer

Championing Health Care as a Human Right:
An Interview with Paul Farmer

"Pathologies of Power is an eloquent plea for a working definition of human rights that would not neglect the most basic rights of all: food, shelter, and health."
—Tracy Kidder, author of Mountains Beyond Mountains, a book about Paul Farmer

UC Press Executive Editor Naomi Schneider interviewed Paul Farmer, Professor of Medical Anthropology at Harvard Medical School and Founding Director of Partners in Health. The University of California Press recently published his book Pathologies of Power: Health, Human Rights, and the New War on the Poor. Farmer is the winner of a MacArthur Foundation "genius" award and the Margaret Mead Award for his contributions to public anthropology.

Tell us a little about your background. Did you grow up in an activist family?

Well, not an activist family in the "conventional" sense. My parents were in some senses working class (my mother, a farm girl, was a grocery-store cashier; my father went to teacher's college and was an on-again-off-again teacher) but in others were very unusual. I'm one of six kids, and the eight of us lived for over a decade in either a bus or a boat. The bus was a former tuberculosis-screening bus and sometimes I wonder . . . But as for activism, my parents did what they could, given the constraints, but were never involved in the causes I think of when I think of activists. They were more engaged in the quiet activism of the trailer parks: my dad, especially, was forever keeping an eye on the elderly, on the mentally challenged (the term back then was "retarded citizens"), or on just about anyone who needed a hand. My mother, of course, was keeping an eye on my dad, who needed a lot of tending, and on her six young kids. She had all of us by the time she was in her late twenties.

Why did you decide to become a medical anthropologist?

As strange as it seems now, I have to say I just loved the topic. I was in college and took a course in medical anthropology. I loved the readings, the suggested research (I volunteered in a big emergency room), the faculty, the broad view. By the time I was 21, I was dead sure I wanted to be a doctor and an anthropologist. Where that surety came from is now a mystery, but there's no doubt it was there.

What impact does your Catholicism have on your work?

Again, conventional Catholicism does not much appeal to me. Like tens of millions of U.S. citizens, I was "raised" Catholic, but for my agnostic father that meant fulfilling social obligations, including those to his family and that of my mother (both grandmas devout). It was as meaningless to me at 18 as it was to so many other young people. But then came liberation theology, which lent meaning to what I was reading in college (Central America was burning) and, later, to what I was to see and experience in Haiti. I would say that, intellectually, Catholicism had no more impact on me than did social theory. But emotionally and intellectually, liberation theology has been, well, a Godsend-- a resource for living and thinking and writing. It seeps into all of my books, but Pathologies of Power is the first one in which it's sort of front-and-center. Of course, I have no clue, yet, as to whether or not it "works" for the reader. I know it works in Haiti, but I don't have readers here . . .

Did winning the MacArthur spur your ability to raise money and achieve your goals?

Sure. That was 10 years ago, and I learned some lessons. One of them was that books can matter (AIDS and Accusation, my first book, seemed to figure prominently in the view of those who chose us, while prior to the MacArthur, writing seemed firmly put in its place by the illiteracy of those who came to our growing clinic). Another was that recognition of that sort-- the prize was called, I soon learned, "the genius award"-- meant deep ambivalence. After all, ours is fundamentally a group effort, and this was a prize for one person. But there's no question that the prize helped us to raise money and bring attention to our collective work.

Tell us a bit about how you decided to form Partners in Health with some of your colleagues at Harvard. What are its goals and accomplishments so far?

It was apparent from the early 80s that in order to do something lasting and significant in Haiti we would need a springboard in the States. A means of raising funds in order to remediate inequalities of access to health care. PIH was that springboard, and it was a dream of mine from the beginning. The goals are clear enough: go forth and remediate inequalities of access, with the term "access" serving to signal access to education, health care, clean water, whatever. Accomplishments so far? Well, we've worked with our friends in Haiti to establish nothing short of a modern medical center in one of the poorest parts of that country. It works! We've taken on the major health problems of the poorest-- tuberculosis, maternal mortality, AIDS, malaria-- in four countries. We've scored some victories in the sense that we've cured or treated thousands and changed the discourse about what is possible.

Tell us about your program in Haiti. Is it realistic to provide advanced AIDS treatments for the world's poor?

It's realistic because it's real. We've done it in one of the poorest places on the face of the earth for people who don't have access to the basics (food, water, education, housing) and we've done it while fighting for access to these basics. We've even argued that these basics should be rights. Basic birth rights, in our view.

At the same time, we know that it's not realistic. Not in terms of what is likely in a world riven by poverty and social inequalities.

Shuttling back and forth between what is possible and what is likely to occur is instructive and a lot of what shapes our sentiment.

In Pathologies of Power you critique market-based medicine. Why? And what do you propose as an alternative?

I critique market-based medicine not because I haven't seen its heights but because I've seen its depths. Anywhere you have extreme poverty and no national health insurance, no promise of health care regardless of social standing, that's where you see the sharp limitations of market-based health care. The poorest parts of the world are by and large the places in which one can best view the worst of medicine and not because doctors in these countries have different ideas about what constitutes modern medicine. It's the system and its limitations that are to blame.

An alternative? Well, I'm not a specialist in health economics. But there's a simple approach that is not simplistic, at least not in my view. Health care as a right. What sort of right would that be? The right to health care is usually classed as an "economic" or "social" right. And Pathologies of Power is a book about social and economic rights.

You have done groundbreaking work treating drug-resistant tuberculosis patients in Russian prisons, which you discuss in Pathologies of Power. Tell us about how you overcame obstacles from the World Bank and IMF in developing programs for these prisoners.

Well, it remains to be seen that we've "overcome" all the obstacles put in our way. But certainly progress has been made. Tuberculosis is a test case, because we've forced many to accept our basic point that tuberculosis care has to be seen as a right and as a public good. Even die-hard fans of the market acknowledge that TB care should be free. Why? Because it's an airborne disease and treatment equals prevention. Good treatment, that is. Bad treatment leads to drug-resistant TB and death and persistence of the epidemic. Even the bankers have been pushed to acknowledge that some things, including TB treatment, should be considered a public good. The reason, perhaps, that drug-resistant TB in prisons is significant in the international health arena is that it's expensive to treat. Like AIDS. Like malignancies or surgical problems. But it's airborne.

How is adequate medical care a basic human right?

The thing about rights is that in the end you can't prove what should be considered a right. Sure, there are some things we agree on widely (everyone deplores torture) but how long ago was it, in even the liberal democracies, that not everyone was allowed to vote? So I can't show you how, exactly, health care is a basic human right. But what I can argue is that no one should have to die of a disease that is treatable. And I can also show you that people from all walks of life agree that someone who is sick deserves, in principle, compassion and care. In principle. Finally, I can show you all the things that go wrong, not just for the sick but for all of us, when health care is not construed as a basic human right. But in the end it's not really something you can prove.

You are now an academic superstar with a book about you written by Tracy Kidder about to be published by Random House. Is this exciting or a bit disconcerting? How will this celebrity have an impact on your work in Haiti and elsewhere?

Of course it's disconcerting. More so than exciting. I mentioned one of the reasons above: it's a group effort, so anything like this that focuses on me as an individual is disconcerting. There are other reasons to fear celebrity. It's not about us, it's about the patients, about the poor, the struggle.

The recent political turmoil in Haiti is ominous. What is happening in the country and how does this affect your programs?

It's true that political turmoil persists. There are two kinds of turmoil, as I argue in the book. There is the "classic" political turmoil, which has been a feature of living in Haiti for the past 15 years. There is also the turmoil born of poverty and inequality. Haiti has a good chance of defeating the first kind of turmoil, since it has gone, in the 20 years I've been there, from a dictatorship to a democracy. This is necessarily a long and painful process. It affects our programs. Just last month, members of our medical staff were held hostage by former soldiers; our ambulance was stolen and we never recovered it. But things are moving forward.

What are your goals for the next five years?

To scale up our efforts in Haiti, Peru, and Russia. To train a new generation of doctors and scholars and community health workers to take up this idea of health care as a right. I have a couple of ideas about things I'd like to write and these will get done over the next five years. Basically, I guess, more of the same.

To learn more about Partners in Health, visit www.pih.org