pathologies of power

Paul Farmer’s Pathologies of Power is an indictment of the ideological manifestations of neoliberalism in civic and economic structures. Farmer introduces the concept of “structural violence” through a series of case studies based on his medical/anthropological work around the world. The case studies take a broad perspective, intersecting bureaucracy, class, and gender to explore the processes that stratify societies and how civil, social, and economic rights are intimately linked. Farmer’s agenda for the book is one of research and action, deploying a human rights approach to solving problems related to public health and the economy and resisting the “averted gaze” away from structural violence that is indicative of the neoliberal era. The book is split in two parts: chapters 1-4 hinge on Farmer’s experiences in Haiti, Chiapas, and Russia and chapters 5-8 elaborate on Farmer’s human rights approach to solving structural violence around the world.

The foreword to chapter 1 serves as a Farmer’s positionality statement, problematizing the theme of “bearing witness” by highlighting Farmer’s partisan, limited observations from a cultural frame that’s committed to “explaining the presence of pain, affliction, and evil.” Chapter 1 starts with a rhetorical question: how does one quantify suffering? Farmer introduces Acephie and Chouchou’s stories as examples of suffering. Both stories align with observed trends; Acephie, like many women in Haiti, dies from a sexually transmitted disease while Chouchou, like many men in Haiti, dies from violence. Farmer argues a neoliberal approach that emphasizes quantifying suffering (for example, measuring suffering by incidences of sexually transmitted diseases or incidences of violence) can instead conflate perceptions of “otherness” with the effects of structural violence. Farmer argues for a “modal” approach to understanding suffering that does not hide that other humans are responsible for its occurrence. Farmer outlines the specifics of Acephie and Chouchou’s stories to explain how their social and economic statuses intersect with the structural violence they experience. Acephie was displaced from a farming community in Haiti by a dam construction, found a job as a domestic worker and was fired for getting pregnant, and later died from AIDS. Chouchou criticized road conditions in a public setting in Haiti, was flagged as a dissenter, and was eventually tortured to death by the military and left for dead in a ditch. Acephie’s poverty, race, and gender intersect with ideologically supported structures in Haiti (for example: neoliberal infrastructure projects like dam building; treatment, expected identities, and contingency of domestic workers; gendered stigmatization and treatment of AIDS patients; and unequal access to medical treatment). Similarly, Chouchou’s poverty, race, and gender intersect with ideologically supported structures in Haiti (for example: neoliberally supported strongman governments; eradication of free speech by intimidation and violence; rationalizing extreme violence as an adequate solution to crime; and a non-existent or ineffective judicial system). Having set his agenda and methods, Farmer continues with examples of similar processes he observed again in Haiti, in Chiapas, and in Russia.

Chapter 5 lays out Farmer’s framework for preferential options for the poor which rely on observation, judgement, and action and are largely shaped by liberation theology. Farmer enacts this framework through the case study of tuberculosis: his observation deconstructs the biological and social approaches for solving tuberculosis problems in the world; his judgement states that the full eradication of a curable disease that predominantly affects the poor is a worthy and logical goal; and his action is a community centric approach to tuberculosis treatment in Haiti that removes the structural barriers to compliance and thus addresses both the medical and the social factors that contribute to the disease’s hardiness. Farmer then criticizes charity and development approaches to solving world problems alluding to Freire’s Pedagogy of the Oppressed. Chapters 6-8 apply this framework in terms of medicine as commerce, tuberculosis as punishment, and medical ethics as lacking.

Farmer’s last chapter rethinks health in terms of human rights, noting that the gap between idealized and actual human rights is growing worldwide. He returns to liberation theology as a compass for pragmatic service in solidarity with the poor and notes the importance between strategy (“who did what to whom and when”) and strategy (“what can be done”) when designing and enacting social justice interventions. Farmer ends with six suggestions to advance health and human rights: setting health and healing at the core of one’s agenda, having service central to one’s agenda, establishing new research agendas, assuming a broader international mandate, behaving independently in these endeavors, and securing more resources for the nascent health and human rights movement.

Farmer’s book has the strongest sense of urgency from the selection of books we’ve read for this course so far, given the life or death stakes that Farmer’s medical research operates in and the bioethics perspective he promotes. Given this urgency, Farmer’s book also reads as the most directly political, with previous authors we read in this course more likely to disguise their politics behind their traditional academic research agendas and theories. Not that previous author’s politics weren’t at the forefront of their work, but Farmer constantly reminds us about engaging in ethical research in commitment and solidarity with the poor.


Farmer, Paul. 2004. Pathologies of Power: Health, Human Rights, and the New War on the Poor. University of California Press.

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