Hum Rights Rev (2011) 12:545–547 DOI 10.1007/s12142-011-0205-z BOOK REVIEW

Partner to the Poor: A Paul Farmer Reader by Paul Farmer Berkeley, CA: University of California Press, 2010 Anthony Tirado Chase

Published online: 19 October 2011 # Springer Science+Business Media B.V. 2011

Paul Farmer’s Partner to the Poor is introduced by Haun Sassy with the following: “People sometimes refer to Paul Edward Farmer, MD, born in 1959, as a hero, saint, madman, or genius. Any or all of these descriptions may hold….” (1). This hagiographic (literally) beginning gives some sense of the impressive impact of Farmer’s writings collected in Partner to the Poor. It also, represents, however, something of a conundrum. How does one balance admiration for the resonance of Farmer’s important work with the troubling sense that Farmer’s invocations of human rights lack the depth to effect the change for which he calls? A deeper understanding of human rights than Farmer’s may be necessary if his initially appealing invocations are to move away from the problematic assumption that human rights are something to be given from the outside, rather than owned by marginalized populations that engage with the rights’ regime to the degree it resonates with their own struggles. That Farmer’s persona and writings are powerful is clear. He is a charismatic figure who has brought urgently needed attention to the structurally embedded nature of ill health. His projects with Partners in Health first in Haiti and then in other parts of the world have been part of a crusade to bring health care to the world’s disenfranchised. In Partner to the Poor, as elsewhere, Farmer is a populizer of concepts such as “structural violence” and “health and human rights.” He draws on these concepts as a way to highlight what he calls the “biosocial” basis of disease—i.e., that causes of disease are as much economic and social as biological (153–154). His writings in this regard have an elegant directness and passion that accounts for their deserved popularity. It is a quibble to note that the writings in this collection are repetitive and somewhat derivative. More important than such a quibble is that Farmer crystallizes a persuasive and important message: that blaming disease on cultural behavior or biological chance misses the ways in which embedded poverty creates vulnerability to ill health and to disease.

A. T. Chase (*) Occidental College, Los Angeles, USA e-mail: [email protected]

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This is a message with powerful implications for how better and more equitable public health results can be accomplished. In “Ethnography, Social Analysis, and Prevention,” Farmer is at his most direct in drawing on Nancy Krieger’s pathbreaking public health work (122) and Jonathan Mann’s conceptualization of “health and human rights” (130) to ask “how, precisely, do social forces (such as poverty, sexism, and other forms of discrimination) translate into risk for infection with HIV [and other diseases]?” (122). This basic question recurs throughout Partner to the Poor, often married to the phrase “structural violence” that flows out of Farmer’s training in anthropology and sympathy with liberation theology. The result is a rhetorically compelling call to focus public health attention on the globe’s disenfranchised and the structural reasons behind that disenfranchisement, a call tangibly reinforced by Farmer’s work in the field. What is less clear, however, is if Farmer substantively addresses the theoretical and practical implications of his critique of the public health status quo. The repetition in Partner to the Poor’s 25 pieces indicates that Farmer’s ideas are perhaps more repeated than they are developed; a smattering of academic jargon adds nothing of substance. But, as noted above, there is certainly an important place for a populizer who hammers home important ideas. More problematic, however, is that this lack of development indicates a disconnect between the idea of focusing on social and economic causes of ill health and what this might mean in practice. One waits for detail of what Farmer’s critique of structural violence entails and, finally, Farmer writes, “There is no secret formula, only brute needs. I mentioned food, and also sutures, medications, electricity, water, and other basic goods that may not seem very sexy to most people now commenting on health and human rights. Is this all there is to it? …. We at PIH have [also] found the recruitment and training of community health workers to be a means of working simultaneously on several aspects of the tangle of poverty and disease.” (522) Is that, indeed, all there is to it? For all of his rhetorical calls to action, Farmer’s writings in Partner to the Poor and the work it describes is less than radical; indeed, it most resembles traditional development work mixed with humanitarian charity (with perhaps a dash of a liberation theologian’s missionary zeal). While Farmer invokes the language of structural violence and human rights, it does not lead to anything more novel than a call for resource transfers and provision of services. There is not, necessarily, anything wrong with that. Many rhetorically invoke an abstract idea of human rights in a way that undergirds an admirable ethical outlook of solidarity with the world’s most vulnerable. No doubt there is good that flows out of such impulses, albeit not fundamental change that addresses the structures that sustain poverty and vulnerability. At its most specific and applied, however, human rights can (and should) go further. They can give an anchor calling states to account for obligations to respect a panoply of rights—rights that range from the right to health to the right to protection from discrimination to many other intersecting rights (or, more precisely, the obligation to respect, protect, and fulfill each of those rights). Farmer’s approach to rights is that they must be given from the outside to victims, with little sense of agency or differentiated power dynamics in distinct parts of the world. A more substantive rights-based approach is more radical in its grounding in the idea that rights cannot be fulfilled in isolation from one another and without rights-holders on the ground spearheading rights claims. It is

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puzzling that Farmer indicates disapproval for such a notion of the indivisibility of rights or the potential agency of peoples. He prefers a conceptualization in which the right to health is provided rather than empowering peoples to address a range of intersecting rights in a way that fundamentally challenges the foundations of the structural violence that marginalizes populations and makes them vulnerable to poverty and ill health. No matter how many goods and medicines are provided, it is, in fact, hard to imagine the right to health fulfilled separate from rights such as the right to non-discrimination or the right to education or the right to information or the right to free expression (through which peoples can articulate and make claims for their rights). To the degree that rights can give a tool for those structurally disadvantaged within a society to make claims relevant to their political–economic–social needs, they are a way to directly address the structural violence that Farmer properly highlights. This moves well beyond the provision of charity that will always be dependent on the missionary savior. Focusing less on provision of services and more on how human rights can be used to hold governments to account for discriminatory power structures is difficult; there is not the immediate gratification of providing a direct charity service and the knowledge that one has, at least, improved or even saved an individual life or the lives of some numbers of people. It may even be that charity is preferable to worrying about the nitty-gritty of challenging the political, economic, and social rights’ violations that create vulnerability to ill health. But it may also be that marrying the rhetoric of rights to the practice of charity flows out of a dangerously flawed conception of rights as given from on high, rather being a matter of struggle and empowerment from below. This may elicit hagiographic praise, but leave little fundamentally changed. Readers of Partner to the Poor will have to struggle with precisely this conundrum: is Paul Farmer a savior? A hero? A saint? Or a good doctor doing excellent works whose rhetoric promises more than it conceptually delivers?