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Global Health Assignment
At first glance, the contents of this week’s readings present very different scenarios of health and health care for countries of the developed world, including the US (in Crisp 2010), and developing world, including Bangladesh and Haiti,(in Crisp 2010 and Farmer 2005). Yet both authors set their analyses in the context of global health and the interconnections within and between developed and developing countries. Your task for the Week One essay is to do the readings carefully and consider what those interconnections are. These make health problems in all these countries ultimately relevant to all of us; thus, we refer to them as global health issues. There are three steps you need to take to writing a strong paper. STEP ONE: Explore this COVID-19 interactive link https://coronavirus.jhu.edu/map.html. Observe the data available in all continents. Pay special attention to developed (richer) and developing (poorer) countries and compare their situations. Pick a couple of very specific examples from the link and discuss them briefly. STEP TWO: Select one of the following examples discussed in the readings, either the “water refugees” in Haiti (in Farmer’s book), or the impoverished rural Bangladeshis (in Crisp’s book), and present the case, keeping in mind its connection to structural violence, which is the central concept we are addressing this week. STEP THREE: Answer the following question: Why should the poor health of Haitians’ “water refugees,” OR of impoverished rural Bangladeshis matter to us in the U.S. Here you bring it altogether taking into consideration the conditions we are experiencing under COVID-19.

Note: This is how should you format your paper:

1. Give a title to your paper (i.e. “Week One Paper”; “Understanding Global Health…”; ext.) 
2. Length: 2-3 page long, not including List of References, which you need to add at the end (see syllabus for more details).  About 1-2 paragraphs per each of the steps you are required to address for the paper.
3. Double-space text with Times New Roman font size 12.
4. Personal Details: ALWAYS include your full name and student number in your weekly papers.
5. Remember to demonstrate that you have carefully and thoroughly done the required readings. ALWAYS acknowledge your sources in-text AND in the List of References at the end (see syllabus for more detail).

Information that you need for this paper will be on Crisp (2010, pp. 1-39) & Farmer (2005, pp. 1-50)
Books will added in the pdf format!!!

Turning the World Upside Down:
the search for global health in the twenty-first century

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Turning the World Upside
Down: the search for global
health in the twenty-first century

Nigel Crisp

© 2010 Royal Society of Medicine Press Ltd

Published by the Royal Society of Medicine Press Ltd
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Phototypeset by MTC Manila
Cover photograph by Kate Holt reproduced by permission of Sightsavers International
Some figures by Jonathan Bosley of HLM Architects
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www.rsmpress.co.uk

Preface vii

List of Abbreviations Used ix

1. Introduction 1

2. Health and poverty 18

3. Health and wealth 40

4. Unfair trade (1) – exporting health workers 64

5. Unfair trade (2) – importing ideas and ideology 82

6. Learning from low- and middle-income countries 105

7. Practical knowledge for the twenty-first century
(1) – people and patients 127

8. Practical knowledge for the twenty-first century
(2) – science and systems 149

9. The paradigm shift to global health 176

10. Action 197

Index 211

About the Author 228

Contents

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�ii

Preface

There are two simple ideas at the very heart of this book – that rich countries can learn a
great deal about health and health services from poorer ones and that combining the learn-
ing from rich and poor countries can give us new insight into how to improve health.

Having run the world’s biggest health service, England’s NHS, for more than 5 years, I
was asked by Prime Minister Blair to look at how we could use all the accumulated experi-
ence and expertise about health which we had in the UK to improve health in developing
countries. As I travelled the world at his request, meeting people and visiting services, I
began to see that there were indeed many ways in which we could help, that many British
health workers and organisations wanted to help and, indeed, many were already doing so.

I also began to realise, however, that creative, passionate local people in countries that
didn’t have our resources, were innovating, finding solutions and working out how to use
the materials at hand to provide the best deal they could for their patients. Unconstrained
by our history, conventions and institutions, they were training people differently, creat-
ing new types of organisations, involving families and communities, and concentrating
much more on promoting health and independence rather than on just tackling disease.

There is no comparison, of course, between the problems to be found in the poor-
est parts of the world and those in rich countries like the UK. Ill health, poverty, life
expectancy and disability are all so much worse in the poorer countries. People die and
are damaged by some of the simplest and most treatable or preventable diseases and situ-
ations. It is plain to see that science, technology, medicine, professionalism, knowledge
and systems, combined with more resources and health workers are desperately needed.
It is also plain and obvious, however, that health systems in rich countries are in trouble.
Whilst poorer countries need more of what we in richer countries have – our science and
expertise – perhaps we also need more of what they have learned.

This very simple idea has led me to recognise that talking about developing and de-
veloped countries and about international development can be very misleading. We all
have something to learn and all have something to teach. We are in this together and
we will develop together. I have used instead the expressions richer and poorer countries
and, in doing so, recognised that there is a spectrum. There are very rich and very poor
and many in between, all of them with their own particular circumstances and features –
however it is the richer that have most of the power and who determine the way the
world’s institutions and relationships work, and the poorer who have to live within a
world shaped by others.

I have used many examples and illustrations from my own experience and observations
– drawing on my time in the NHS and my experiences working on global programmes

�iii

to train more health workers in poorer countries. I have also used examples from my role
as Chair of Sightsavers International, which works with local partners in 33 countries
to prevent blindness, treat eye disease and help blind and partially sighted people live as
independent lives as possible.

I am grateful to the many people who have allowed me to tell a part of their story and
to them and the many others from whom I have learned. I have used their examples to
bring the book to life and ground it in reality.

Turning the World Upside Down is in many ways a description of what is happening
now and of the things which innovative health workers, leaders and politicians are doing
today. It describes people learning how to work more effectively and how to have a greater
impact and is written in conscious admiration of the many millions of health workers
worldwide who work with such compassion, determination and imagination. They, not I,
are the people who are creating the new vision for health that I describe in this book.

I am deeply grateful to many people who have taught me about their countries and
continents including Francis Omaswa, Bience Gawanas, Fazle Hassan Abed and Srinath
Reddy as well as to Don Berwick, Maureen Bisognano and colleagues from the Institute
for Healthcare Improvement for their inspiration and insight; Mary Robinson, Peggy
Clark and colleagues from Realizing Rights for helping me understand human rights and
health; Michael Birt and colleagues at the Pacific Health Summit for introducing me to
new ideas; Margaret Chan, Tim Evans and colleagues at the World Health Organization;
Joy Phumaphi, Julian Schweitzer and colleagues from the World Bank; and Ernest Massiah,
Peggy Vidot and colleagues from the Commonwealth Secretariat, for their continuing
support and guidance.

I have been privileged to work with many people in The Global Health Workforce Al-
liance and the Gates Foundation and to have been accompanied on my earlier travels by
Imogen Sharp and Amy Kesterton. Throughout, I have also been very fortunate to have
been able to call on help from so many people in the UK’s Department for International
Development and Foreign Office; both of whom have proved to be unparalleled sources
of insight and understanding. It has been a pleasure to see how highly they are regarded in
the countries where they work. The UK is a global leader in international development. I
am also very fortunate to have been able to call on help from the Department of Health
and benefit from the expertise of many of its staff.

I am also indebted to the people who read and improved parts of this book who include,
as well as some of the above, John Bacon, Kate Barnard, Vivian Bazalgette, Ali Enayati,
Ruth English, Phil Freeman, David Jenkins, Anna Maslin, Joe McCannon, Debbie Mellor,
Eldryd Parry, David Percy and Paddy Salmon.

Susana Edjang has done an outstanding job as my researcher, providing me with the
evidence, analysis and references I needed and offering me her own insight. The book is
much the richer for her contribution.

Finally and above all, I am grateful to Siân, Madeleine and Alastair for their advice on
science and anthropology and their – almost – unqualified understanding and support
over the last year.

Nigel Crisp
Tutts Clump
December 2009

Preface

ix

List of Abbreviations Used

ACE Angiotensin-converting enzyme
AIDS Acquired immune deficiency syndrome
ANC African National Congress
API Associates in Performance Improvement
ART Anti-Retroviral Therapy
ASHAs Accredited Social Health Workers
BRAC Bangladesh Rural Action Committee
CAN Community Action Network
DFID Department for International Development
DVT Deep vein thrombosis
FDA Food and Drug Administration
GAVI Global Action on Vaccination and Immunization
GSK GlaxoSmithKline
HIPC Highly Indebted Poor Countries Initiative
HIV Human immunodeficiency virus
ICT information and communication technology
IFMSA International Federation of Medical Student Associations
IHI Institute for Healthcare Improvement
IHP International Health Partnerships
IMF International Monetary Fund
MCN Movimiento Comunal Nicaragüense
MDRI Multilateral Debt Relief Initiative
MHRA Medicines and Healthcare products Regulatory Agency
MMR Measles, mumps and rubella
MOH Ministry of Health
MRSA Methicillin-resistant Staphylococcus aureus
NGO Non-governmental organisation
NICE National Institute for Health and Clinical Excellence
PAHO Pan American Organization for Health
PEPFAR President’s Emergency Plan for AIDS Relief
SARS Severe Acute Respiratory Syndrome
SCF South Central Foundation
TB Tuberculosis
THET Tropical Health Education Trust
UN United Nations
URC University Research Company
USAID United States Agency for International Development
WHO World Health Organization

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Diseases travel; the microbe that boards a plane in Cambodia this morning can be in
Washington before the sun has set. The Internet provides information and knowledge but
also spreads ignorance, prejudice and superstition to every part of the world. Science and
technology create enormous benefit but can also bring new environmental and biological
perils, which, like climate change, will affect us all.

The most striking thing about health in the twenty-first century is that the whole world
is now so interconnected and so interdependent. This interdependence is changing the way
we see health, creating a new global perspective and will affect the way we need to act.

Turning the World Upside Down is a search to understand what is happening and what
it means for us. It is based on my own journey from running the largest health system in
the world to working in some of the poorest countries and draws on my experience and
experiences to explore new ideas and innovations from around the world.

It argues that western scientific medicine, which has been such a dominant and success-
ful force in the world, is no longer by itself capable of continuing to improve our health.
We need to understand how to make the best use of our ever-improving scientific knowl-
edge and technology. Unless we take account of the new global dimension we will be in
constant danger of using twentieth-century ideas and tools to tackle twenty-first-century
problems. We need a paradigm shift towards a global perspective, towards global health.

This chapter sets the scene, describes the wider context and discusses global health
itself, by which we mean everything that affects us all, wherever we live, from global
warming and the spread of disease to the migration of health workers and the availability
of medicines.

The search for understanding

Our search for understanding starts by looking at the current state of health and health-
care in the different parts of the world. A simple story illustrates just how successful west-
ern scientific medicine has been and how much health has improved for the populations
of rich western countries in the last century.

Life in the mountains and valleys of South Wales was much tougher in the 1920s and
1930s than it is today and life expectancy was shorter. Half the population didn’t reach
retirement age, about 1 in 250 women died in childbirth, there was no health system for
the poor and tuberculosis (TB) was rampant. It must have seemed to many people that
things would never improve.

Introduction1

Introduction

Ben Jenkins owned and operated a timber yard in Brecon and lived next door to it with
his wife, nine children and a maid. They were a relatively prosperous family and lived a
very different life from the miners in the valleys nearby, who were constantly at risk from
work-related diseases and the dangers of the coal mines. They were not poor and could
afford to call the doctor; nevertheless, the Jenkins family faced tragedy.

Trevor, the eldest child, caught TB whilst working away from home and died aged 21
in 1929. Tragically, he had brought the disease home with him and most of the family
were affected. Several were sent to sanatoria higher in the mountains and two went to
Switzerland in an effort to recover or escape the disease altogether. The treatment was only
partially successful and Ben and both his daughters, Winifred and Betty, died of TB in
the following years.

David, the seventh son and youngest child recalls being sent to a sanatorium for a
whole year at the age of 8 in 1931. His mother, who by this time had seen her husband
and others of her children sicken, couldn’t bear to say goodbye to another one, pos-
sibly for the last time, so the small boy found himself sent away with strangers in a vast
hospital not knowing what was happening to him and unable to communicate with his
family.

The other children lived but the mother died, of a broken heart according to family
legend, although in reality of a brain tumour, in the week that her youngest child, David,
went off to join his remaining brothers at war in 1942.

It was not just TB that was such a killer at the time. The story in those Welsh hills
was that one funeral led to another. Standing hatless in the rain mourners were at risk of
pneumonia, still a regular killer in those pre-antibiotic days.

Today, having survived the risks of TB, pneumonia and war, my father-in-law David
Jenkins is 85. Three of his elder brothers, two in their 90s, attended his and Elaine’s 60th
wedding anniversary party last year. The Jenkins family can trace the story of how health
has been transformed in the UK through the history of their own family, where the eldest
died young and the youngest survive today.

The experience of the Jenkins family was by no means unique and life expectancy in
the UK increased by 30 years in the last century. That is 3 years in every decade or almost
8 hours more for every day that we lived. One need only translate this through into one’s
own life to see how significant this is. My life expectancy at birth was about 65. It is now
above 80. I am truly very grateful to all concerned.

It’s not just about life expectancy, of course. We are healthier and fitter in our 50s,
60s, 70s and 80s and beyond than our parents were at the same age. We have ‘won-
der’ drugs that allow us to manage our heart disease and other conditions and we have
replacement hips, knees and lenses that give us so much more freedom from our dis-
abilities. We are much richer now as a society in the UK and therefore much more able
to acquire labour-saving, life-enhancing devices and drugs than at any time in human
history.

We can see how health has improved enormously over the last century but we can
also see that continuing growth in health services and funding is now only producing
marginal benefits. It is the same story in many rich countries where massive increases in
expenditure in recent years, planned as in the UK or unplanned as in the USA, have led
to improvements but have not transformed health services. At the same time the public is

becoming more assertive, harder to please and less willing simply to follow medical advice
and be passive and patient.

Looking more deeply we can see that part of the reason for these problems and the dis-
satisfaction of the public is that the most significant diseases of the twenty-first century
in richer countries are different from those in the twentieth century so that our health
services have to deal with different problems.

We are no longer generally so affected by the communicable diseases like TB; infec-
tions are better controlled, there is less injury and accidental death and many cancers are
becoming manageable chronic diseases. It is now these long-term conditions and non-
communicable diseases, such as cancers, heart disease and diabetes that require the most
attention and use the most resources.

There need to be new and very different ways of dealing with these diseases – with more
services created outside hospital, more involvement of the patient and much greater inte-
gration into other aspects of the patient’s life such as education, employment and leisure
activities. Many, perhaps most, clinicians and health workers have tried to change their
practice accordingly. However, as I can describe from my own experience in the NHS, it
is very difficult in practice to change the way healthcare is delivered.

A major part of the difficulty is that the very factors that led to such improvements in the
twentieth century – the essential features of western scientific medicine: scientific discovery,
greater professionalism, commercial innovation and massively increased funding – are so
invested in maintaining and developing the old models of delivery and behaviour that they
make it difficult to create new ones and are themselves becoming part of the problem.

We have built up over the years such tremendously strong health systems that they con-
dition what we can do in practice and, in effect, dictate what happens when people are ill.
As a result we may end up in hospital when we don’t need to. We may be overinvestigated,
overmedicated and, in all likelihood, overspent.

More problematically these features of western scientific medicine have also condi-
tioned our mindsets so that we have a very simple model in our minds of what good treat-
ment looks like. We have come to expect treatment by doctors with the latest equipment
and drugs in specialist facilities and hospitals, whether or not this is actually what we need
for our particular problem or illness. Good treatment for our condition may actually be
something else altogether.

The dominance of this way of thinking amongst politicians, health leaders and the
public is so great that most attempts at reforming health systems in richer countries have
concentrated on getting the best out of the existing model, through improving the exist-
ing arrangements, incentivising doctors differently and making more productive use of
equipment and facilities. These reforms have not, despite great rhetoric, generally led in
any major way to designing completely different services and systems suitable for the lon-
ger term conditions and chronic diseases we now face, let alone produced a major swing
towards health promotion and disease prevention.

Existing power structures and vested interests reinforce this dominance at every turn.
Almost any change, any innovation and any improvement will disadvantage somebody.
Moving services to the community reduces hospital income. The empowerment of nurses
and patients, which may be necessary to improve health, reduces the power of the doctors
and commercial companies.

The search for understanding

Introduction

Whilst many doctors, hospital chief executives and businesses, as I shall describe in
later chapters, are leading innovators and driving many of the improvements in the world,
their professional and business associations recognise the threat to their power bases and
react accordingly by opposing the change. This has happened time and again over the
years, as when the UK’s British Medical Association, the doctors’ trade union, opposed
the establishment of the NHS in 1948 until they were bought off, their “mouths stuffed
with gold” in the words of the NHS founder Aneurin Bevin.

This history shows that it requires not only great political leadership and resolve to
drive change in a complex field like health but also consummate political skill to gener-
ate support and energy and negotiate around the obstacles. Politicians around the world
know to their cost just how difficult this can be.

From Wales to Bangladesh

Turning to low- and middle-income countries we find that in many of them, just like in
Wales in the 1920s, half the population does not reach the equivalent of retirement age, 1
in 250 women die in childbirth, there is no health system for the poor and TB is rampant.
It must seem to many people that things will never improve.

I recalled the Jenkins family history as I flew back from Bangladesh in 2008 and
thought about the poverty and the illness I had seen there. What were the chances of
a similar transformation in Bangladesh, I wondered? More importantly, why wasn’t it
already happening? We know what to do clinically about all the most common diseases
and problems. There has been an enormous investment in aid and development. It seemed
outrageous that it wasn’t just happening. What was getting in the way?

I had begun to think about these issues when the Prime Minister, Tony Blair, had asked
me to consider what more the UK could do to use its experience and expertise to help
improve health in developing countries.1 I had reported to him in 2007 but had remained
involved in health globally. On this occasion, as Chair of Sightsavers, I had been visiting
eye services in Bangladesh and had been reminded by my visit of the enormous contrast
there was between health in richer and poorer countries.

I had spent more than 5 years as the Chief Executive of England’s National Health
Service. It is the largest integrated health service and the fourth biggest organisation in
the world with 1.3 million employees and a turnover of almost £100 billion a year. Only
the Chinese Army, the Indian railways and Wal-Mart are larger.

In some ways these organisations seem to reflect the countries themselves. They draw
attention to China’s power, India’s size and the restless movement of its populations, and
America’s love of commerce. For the UK, the NHS undoubtedly represents something
about us as a nation. It is a universal system; mainly tax funded, which is designed to offer
services to every citizen, equally, regardless of their ability to pay. Love it or hate it, the
NHS says something about the British and our ideas about fairness and compassion.

On that flight from Bangladesh I was coming home from a country that has a very
different way of life and a very different health system, where the majority of the services
provided for the poor aren’t run or sponsored by the Government but by the Bangladesh

From Wales to Bangladesh

Rural Action Committee (BRAC). BRAC is a voluntary organisation, possibly the largest
non-governmental organisation (NGO) in the world, which brings together literally mil-
lions of Bangladeshis in local groups to plan and organise services.

BRAC doesn’t just deal with health, but with education and other public services as
well. It runs empowerment groups for women, teaching them how to take action to
better their lives and those of their families. It has its own microfinance bank to provide
small loans to enable people, mainly women, to earn a living, allowing them to purchase
seed or farming tools or to buy goods that they can sell on in the local markets. It runs a
university and shops and is prepared to be involved and invest in any practical approaches
that benefit the poor.

BRAC is a remarkable example of people who are not prepared to wait for others to
help them but have taken the future into their own hands and are creating their own
solutions. The way they do things challenges the top-down, professionalised and com-
mercialised mindset that is so common in richer countries. Even this short description
shows just how differently services are organized in Bangladesh from the model described
earlier.

Funding is also managed differently. In Bangladesh, as in several other low-income
countries, I saw microfinance systems paying out loans for healthcare and a system of
cross-subsidy in place where those who were able to were expected to pay for their ser-
vices, whilst the poorest got them free. Everyone, however, received the same attention
and the same clinical service.

BRAC, like the NHS, represents an idea, an ideal and a sense of justice and com-
munity. It was founded in 1972 during the country’s struggles for independence from
Pakistan and embodies the values of self-determination and self-sufficiency of that period.
At the very same time that we had been agonising in the NHS over issues like the proper
use of new and expensive technology and of how to get the best value from major new
expenditure, BRAC was struggling in Bangladesh with the consequences of poverty and
neglect and the problem of providing the most basic healthcare to a large part of their
population.

Self-determination and self-help, so well exemplified by BRAC and other organisa-
tions, is a major theme of Turning the World Upside Down and will be referred to in later
chapters. For the moment, however, let us return to my own question of why, despite the
efforts of inspiring organisations like BRAC and despite the years of aid, big improve-
ments were not already happening? Three reasons stand out. There are three levels of
problems to confront at the same time; each is formidable and together they show how
extremely difficult it is to make a truly transformational change.

Firstly, dealing purely with health issues, there is simply very much more disease and very
many more causes of disease, injury and death than we now see in richer countries. Com-
municable diseases such as malaria, TB and human immunodeficiency virus (HIV)/acquired
immune deficiency syndrome (AIDS) are rife in many countries, the non-communicable
diseases are becoming more common and injury and death from conflict, traffic accidents
and employment are widespread. Sub-Saharan Africa alone, with one tenth of the world’s
population has almost one-quarter of the world’s burden of diseases.

At the second level, poverty affects health in myriad ways and makes it much harder to
make improvements. One billion people around the world live in desperate poverty on

Introduction

less than a dollar a day; another billion scrape a living with little more than two dollars a
day. It is not, of course, as if the dollar or two are available every day: some days it may
be more, some days less or nothing. They are living on the edge and can easily be pushed
over it into destitution, famine and death by disease, climate or war.

The health of many of the poorest people in the poorest countries is truly dreadful. The
statistics are now so often repeated that they can easily be ignored; unless, of course, you
decide to make it personal by thinking about your own children or relatives when you
hear that one in five children die before the age of 5 in some parts of Sub-Saharan Africa.2
It is almost worse to know that most of these deaths could so easily be avoided, even in
the poorest countries, if there were clean water, insecticide-treated mosquito bed nets, ad-
equate food and housing and better access to simple treatment, advice and education. All
of these contribute to health whilst their absence leaves the way clear for illness, disability
and death. People need more than just health services to improve their health.

Poverty also means that in many countries there is no health system to speak of, with
few facilities and with difficulties in staffing and providing drugs, particularly in rural
areas. Where health systems in richer countries may be too strong, they are often peril-
ously weak in poorer ones and access to care may be haphazard, of uncertain quality and,
where available, very costly.

At the third and deepest level we can also see how social, economic and political factors
affect health profoundly within a country. The education of women is crucial in securing
the health of their children whilst their own position in society often dictates whether
they can …

PRAISE FOR PAUL FARMER’S PATHOLOGIES OF POWER

“In his compelling book, Farmer captures the central dilemma of our times—the
increasing disparities of health and well-being within and among societies.
While all member countries of the United Nations denounce the gross viola-
tions of human rights perpetrated by those who torture, murder, or imprison
without due process, the insidious violations of human rights due to structural
violence involving the denial of economic opportunity, decent housing, or ac-
cess to health care and education are commonly ignored. Pathologies of Power
makes a powerful case that our very humanity is threatened by our collective
failure to end these abuses.”

ROBERT S. LAWRENCE, President of Physicians for Human Rights and Professor
of Preventive Medicine, Johns Hopkins University

“Pathologies of Power is a passionate critique of conventional biomedical ethics
by one of the world’s leading physician-anthropologists and public intellectu-
als. Farmer’s on-the-ground analysis of the relentless march of the AIDS epi-
demic and multidrug-resistant tuberculosis among the imprisoned and the sick-
poor of the world illuminates the pathologies of a world economy that has lost
its soul.”

NANCY SCHEPER-HUGHES, author of Death without Weeping: The Violence of
Everyday Life in Brazil

“Wedding medicine and anthropology, painstaking clinical and field observation
with rigorous conceptual elaboration, Farmer gives us that most rare of books:
one that opens both our minds and hearts. Pathologies of Power uses the prism
of public health to illuminate the structural forces that decide the ‘right to sur-
vive’ on the global stage. From Haiti to Russia to the United States, Farmer re-
veals the drama of the social production of mass sickness, suffering, and death
without dramatizing, and then grapples with the tough moral issues without
moralizing. He shows how market rule results in vertiginous violations of basic
social and economic rights that in turn translate into escalating pathologies that
ravage the poor. This book stands as a model of engaged scholarship and an
urgent call for social scientists to forsake their cushy disregard for human rights
at home and abroad.”

LOÏC WACQUANT, author of Prisons of Poverty

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PATHOLOGIES OF POWER

Farmer_FM_i-xxiv 11/26/02 12:43 PM Page i

CALIFORNIA SERIES IN PUBLIC ANTHROPOLOGY

The California Series in Public Anthropology emphasizes the anthropologist’s
role as an engaged intellectual. It continues anthropology’s commitment to being
an ethnographic witness, to describing, in human terms, how life is lived beyond
the borders of many readers’ experiences. But it also adds a commitment, through
ethnography, to reframing the terms of public debate—transforming received,
accepted understandings of social issues with new insights, new framings.

series editor: Robert Borofsky (Hawaii Pacific)

contributing editors: Nancy Scheper-Hughes (UC Berkeley), Philippe
Bourgois (UC San Francisco), and Arturo Escobar (University of North
Carolina)

university of california press editor: Naomi Schneider

1. Twice Dead: Organ Transplants and the Reinvention of Death,
by Margaret Lock

2. Birthing the Nation: Strategies of Palestinian Women in Israel,
by Rhoda Ann Kanaaneh; with a Foreword by Hannan Ashrawi

3. Annihilating Difference: The Anthropology of Genocide,
edited by Alexander Laban Hinton, with a Foreword by Kenneth Roth

4. Pathologies of Power: Health, Human Rights, and the New War
on the Poor, by Paul Farmer; with a Foreword by Amartya Sen

Farmer_FM_i-xxiv 11/26/02 12:43 PM Page ii

PATHOLOGIES OF POWER
HEALTH, HUMAN RIGHTS, AND THE NEW WAR ON THE POOR

PAUL FARMER
WITH A FOREWORD BY AMARTYA SEN

UNIVERSITY OF CALIFORNIA PRESS
Berkeley . Los Angeles . London

Farmer_FM_i-xxiv 11/26/02 12:43 PM Page iii

University of California Press
Berkeley and Los Angeles, California

University of California Press, Ltd.
London, England

© 2003 by the Regents of the University of California

Material included in Chapters 1 to 7 and 9 has been adapted from earlier
work by the author, which appeared in the following publications: “On
Suffering and Structural Violence: A View from Below,” Daedalus 125,
no. 1 (1996): 261 – 83; “On Guantánamo,” in The Uses of Haiti, by P. E.
Farmer (Monroe, Maine: Common Courage Press, 1994); “A Visit to
Chiapas,” America 178, no. 10 (1998): 14 – 18; “TB Superbugs: The
Coming Plague on All Our Houses,” Natural History 108, no. 3 (1999):
46 – 53; “Medicine and Social Justice,” America 173, no. 2 (1995):
13 – 17; “Listening for Prophetic Voices in Medicine,” America 177, no. 1
(1997): 83 – 85; “Cruel and Unusual: Drug-Resistant Tuberculosis as
Punishment,” in Sentenced to Die? The Problem of TB in Prisons in East
and Central Europe and Central Asia, edited by V. Stern and R. Jones
(London: International Centre for Prison Studies, King’s College, 1999);
“Pathologies of Power: Rethinking Health and Human Rights,” American
Journal of Public Health 89, no. 10 (1999): 1486 – 96.

For use of the quotations in the epigraphs in this book, grateful acknowl-
edgment is made to the authors and publishers, as listed on pages 379–81
and deemed part of this copyright page.

Library of Congress Cataloging-in-Publication Data

Farmer, Paul
Pathologies of power : health, human rights, and

the new war on the poor / Paul Farmer ; with a
foreword by Amartya Sen.

p. cm. — (California series in public
anthropology ; 4)
Includes bibliographical references and index.
isbn 0–520–23550–9 (Cloth : alk. paper)
1. Social stratification. 2. Equality. 3. Poor—

Medical care. 4. Discrimination in medical care.
5. Right to health care. 6. Human rights.
I. Title. II. Series.
hm821.f37 2003
305—dc21 2002013311

Manufactured in the United States of America

12 11 10 09 08 07 06 05 04 03

10 9 8 7 6 5 4 3 2 1

The paper used in this publication meets the minimum requirements of
ANSI/NISO Z39 0.48 – 1992 (R 1997) (Permanence of Paper).

Farmer_FM_i-xxiv 11/26/02 12:43 PM Page iv

Our system is one of detachment: to keep silenced people from
asking questions, to keep the judged from judging, to keep
solitary people from joining together, and the soul from putting
together its pieces.

Eduardo Galeano, “Divorces”

FOR OPHELIA, LOUNE, JIM, AND TOM,

MY PARTNERS IN HEALTH

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Farmer_FM_i-xxiv 11/26/02 12:43 PM Page vi

Sometimes the lack of substantive freedoms relates directly to
economic poverty, which robs people of the freedom to satisfy
hunger, or to achieve sufficient nutrition, or to obtain remedies
for treatable illnesses, or the opportunity to be adequately
clothed or sheltered, or to enjoy clean water or sanitary
facilities.

In other cases, the unfreedom links closely to the lack of public
facilities and social care, such as the absence of epidemiological
programs, or of organized arrangements for health care or
educational facilities, or of effective institutions for the
maintenance of local peace and order.

In still other cases, the violation of freedom results directly
from a denial of political and civil liberties by authoritarian
regimes and from imposed restrictions on the freedom to
participate in the social, political and economic life of the
community.

Amartya Sen, Development as Freedom

Rats and roaches live by competition under the law of supply
and demand; it is the privilege of human beings to live under
the laws of justice and mercy.

Wendell Berry

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Farmer_FM_i-xxiv 11/26/02 12:43 PM Page viii

CONTENTS

Foreword by Amartya Sen
xi

Acknowledgments
xix

Introduction
1

PART I. BEARING WITNESS 23

1. On Suffering and Structural Violence 29
Social and Economic Rights in the Global Era

2. Pestilence and Restraint 51
Guantánamo, AIDS, and the Logic of Quarantine

3. Lessons from Chiapas 91

4. A Plague on All Our Houses? 115
Resurgent Tuberculosis inside Russia’s Prisons

PART II. ONE PHYSICIAN’S PERSPECTIVE ON HUMAN RIGHTS 135

5. Health, Healing, and Social Justice 139
Insights from Liberation Theology

6. Listening for Prophetic Voices 160
A Critique of Market-Based Medicine

7. Cruel and Unusual 179
Drug-Resistant Tuberculosis as Punishment

8. New Malaise 196
Medical Ethics and Social Rights in the Global Era

Farmer_FM_i-xxiv 11/26/02 12:43 PM Page ix

9. Rethinking Health and Human Rights 213
Time for a Paradigm Shift

Afterword
247

Notes
257

Bibliography
333

Credits
379

Index
383

Farmer_FM_i-xxiv 11/26/02 12:43 PM Page x

xi

FOREWORD

AMARTYA SEN

Every man who lives is born to die,” wrote John Dryden, some three
hundred years ago. That recognition is tragic enough, but the reality is
sadder still. We try to pack in a few worthwhile things between birth and
death, and quite often succeed. It is, however, hard to achieve anything
significant if, as in sub-Saharan Africa, the median age at death is less
than five years.1 That, I should explain, was the number in Africa in the
early 1990s, before the AIDS epidemic hit hard, making the chances
worse and worse. It is difficult to get reliable statistics, but the evidence
is that the odds are continuing to fall from the already dismal numbers.
Having made it beyond those early years, it may be difficult for us to
imagine how restricted a life so many of our fellow human beings lead,
what little living they manage to do. There is, of course, the wonder of
birth (impossible to recollect), some mother’s milk (sometimes not), the
affection of relatives (often thoroughly disrupted), perhaps some school-
ing (mostly not), a bit of play (amid pestilence and panic), and then things
end (with or without a rumble). The world goes on as if nothing much
has happened.

The situation does, of course, vary from region to region, and from
one group to another. But unnecessary suffering, debilitation, and death
from preventable or controllable illness characterize every country and
every society, to varying extents. As we would expect, the poor countries
in Africa or Asia or Latin America provide crudely obvious illustrations
of severe deprivation, but the phenomenon is present even in the richest

Farmer_FM_i-xxiv 11/26/02 12:43 PM Page xi

countries. Indeed, the deprived groups in the “First World” live, in many
ways, in the “Third.” For example, African Americans in some of the
most prosperous U.S. cities (such as New York, Washington, or San Fran-
cisco) have a lower life expectancy at birth than do most people in im-
mensely poorer China or even India. Indeed, location alone may not en-
hance one’s overall longevity.

EXPLANATION AND REMEDY

How can we come to terms with the extensive presence of such adver-
sity—the most basic privation from which human beings can suffer? Do
we see it simply as a human predicament—an inescapable result of the
frailty of our existence? That would be correct had these sufferings been
really inescapable, but they are far from that. Preventable diseases can
indeed be prevented, curable ailments can certainly be cured, and con-
trollable maladies call out for control. Rather than lamenting the ad-
versity of nature, we have to look for a better comprehension of the so-
cial causes of horror and also of our tolerance of societal abominations.
However, despite many illuminating studies of particular aspects of these
general problems, investigators tend to shy away from posing the ques-
tions in their full generality. To confront the big picture seems like an
overpowering challenge.

Paul Farmer, however, is not easily overpowered. He is a great doc-
tor with massive experience of working against the hardest of diseases
in the most adverse of circumstances, and, at the same time, he is a
proficient and insightful anthropologist with far-reaching discernment
and understanding. Farmer’s knowledge of maladies such as AIDS and
drug-resistant tuberculosis, which he fights on behalf of his indigent pa-
tients, is hard to match. This he combines with his remarkable expertise
on culture and society, acquired not just by learning from a distance but
also from actually living and working in different parts of the deprived
world. In addition, Paul Farmer is a public health interventionist with a
dogged determination to work toward changing iniquitous institutions
and mismatched arrangements. As the co-director of Harvard’s Program
in Infectious Disease and Social Change (working with Dr. Jim Yong
Kim, another remarkable public health expert), Farmer has led several
major initiatives in changing the direction of health care and interven-
tion (for example, in tackling drug-resistant TB).

But what is particularly relevant in appreciating the contribution of
this powerful book is that Paul Farmer is a visionary analyst who can

xii Foreword

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look beyond the details of fragmentary explanations to seek an inte-
grated understanding of a complex reality. In his earlier publications,
including AIDS and Accusation (1992), The Uses of Haiti (1994), and
Infections and Inequalities: The Modern Plagues (1999), he has already
done much to illuminate important features of global deprivations.
Now, in this remarkable book, which is hard to put down, comes the
big picture, firmly linked with informationally rich illustrations of in-
dividual examples.

Farmer points to what he calls “structural violence,” which influences
“the nature and distribution of extreme suffering.” The book is, as he
explains, “a physician-anthropologist’s effort to reveal the ways in which
the most basic right—the right to survive—is trampled in an age of great
affluence.” He argues: “Human rights violations are not accidents; they
are not random in distribution or effect. Rights violations are, rather,
symptoms of deeper pathologies of power and are linked intimately to
the social conditions that so often determine who will suffer abuse and
who will be shielded from harm.” Those “social conditions” and their
discriminatory effects are the subject matter of this general investigation
and the specific case studies that establish the overall picture of power-
lessness and deprivation.

CONCEPTS AND METHODS

Some will undoubtedly ask whether this is not too general, too grand,
and perhaps even too ambitious an inquiry. Also, are the questions ab-
solutely clear? How exactly is “power” defined? Does Farmer delineate
the “social conditions” precisely? Does he provide an exact definition of
“structural violence”? In fact, that is not the way Paul Farmer proceeds,
and it is important to understand the methodology that distinguishes this
wonderful study.

A phenomenon can be either characterized by a terse definition or de-
scribed with examples. It is the latter procedure that Farmer follows.
That procedure is, of course, quite standard when we learn certain basic
words (such as “red” or “smooth”), as Ludwig Wittgenstein (arguably
the greatest philosopher of our times) has famously discussed:

An important part of the training will consist in the teacher’s pointing to
the objects, directing . . . attention to them, and at the same time uttering a
word; for instance the word “slab” as he points to that shape. . . . This os-
tensive teaching of words can be said to establish an association between
the word and the thing.2

Foreword xiii

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Though not so primitive as “red” or “smooth” or a “slab,” terms like
“power” or “violence” can also, often enough, be helpfully communi-
cated through examples.

This is not to deny that we can try to explain these complex terms in
other ways as well, in particular by proposing a precise definition
through the use of other words. That indeed is the usual procedure,
widely used, in the social sciences. And yet, as we know from experi-
ence, this is sometimes highly misleading, since the capacious content of
a social concept or its diverse manifestations may often be lost or di-
minished through the maneuver of trying to define it in sharply delin-
eated terms. The expressions “power,” “structure,” and “violence” are
not eccentric inventions of Paul Farmer; they have figured extensively in
the literature on social inequality.3 But attempts at defining them exactly
by other words have typically been inadequate and unclear (and some-
times they have also generated the kind of “sociological jargon” that can
sound arrestingly weird). For this reason, among others, the alternative
procedure, by exemplification, has many advantages in epistemology and
practical reason in parts of the social sciences. The epigrammatic defini-
tion, which many social scientists seek, often cannot escape being mis-
leadingly exact; it can be precise but precisely inaccurate. A rich phe-
nomenon with inherent ambiguities calls for a characterization that
preserves those shady edges, rather than being drowned in the pretense
that there is a formulaic and sharp delineation waiting to be unearthed
that will exactly separate out all the sheep from all the goats.

Farmer does not fall for the temptation of a make-believe exactness.
While keeping his eyes firmly on the general picture as he sees it, he goes
from one case study to another to explain what “structural violence” is
like (or how disparity of “power” may operate). We see the evident sim-
ilarities as well as the rich variations of form and expression. By learn-
ing from Farmer’s book as a whole, we get an overall understanding that
draws together the diverse details spread across these harrowing ac-
counts.

ACÉPHIE’S POWERLESSNESS

For example, in discussing deprivations in Haiti, Farmer observes that
“political and economic forces have structured risk for AIDS, tubercu-
losis, and, indeed, most other infectious and parasitic diseases” and adds
that “social forces at work there have also structured risk for most forms
of extreme suffering, from hunger to torture and rape.” He discusses in

xiv Foreword

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each case exactly how this structuring of risk, in distinct forms, blights
the lives of many, without touching the affluence of others. He moves
from Haiti to Mexico, then to Russia, then to Peru, then to the United
States, and right across the world, looking for—and insightfully identi-
fying—institutional structures that push some into the abyss, while oth-
ers do just fine. The carefully chosen details in each case help us to un-
derstand Farmer’s notion of “structural violence” through a process that
is not altogether dissimilar to the teaching of the idea of a “slab.”

Indeed, power inequalities can work in many distinct ways. Take the
case of Acéphie, the comely woman born in the small village of Kay
through which runs Rivière Artibonite, Haiti’s largest river. She is lucky
to be born into a prosperous peasant family, but her luck does not last
for long. When the valley is flooded to make room for a reservoir, the
villagers are forced up into the stony hills on the sides of the new lake.
Their voice does not receive a hearing. The displaced people—the “water
refugees”—seek whatever jobs they can get (no longer able to grow the
rice, bananas, millet, corn, or sugarcane they grew so abundantly ear-
lier), and Acéphie’s family ceases to make ends meet. Nevertheless, Acé-
phie—like other young women in families of water refugees—carries the
family’s agricultural produce (miserable as it is) to the local market. The
soldiers, stationed on the way, watch the procession of girls who walk
to the market and often flirt with them. The girls feel lucky to get such
attention, since soldiers are powerful and respected men.

When Captain Jacques Honorat woos the tall and fine-featured Acé-
phie, with her enormous dark eyes, reciprocation eventually follows
(even though Acéphie knows that Honorat is married and has several
other partners). The sexual relation does not last long, but it is enough
to disrupt Acéphie’s life, while Captain Honorat dies of unexplained
fevers. After trying to qualify herself as a domestic servant in the neigh-
boring town of Mirebalais, the twenty-two-year-old Acéphie moves to
Port-au-Prince and finds a servant’s job, at a tiny wage. She also begins
seeing Blanco Nerette, who comes from a similar background (his par-
ents were also water refugees) and now chauffeurs a small bus, and they
plan to marry. However, when Acéphie becomes pregnant, Blanco does
not welcome the news at all. Their relationship founders. Also, thanks
to her pregnancy, Acéphie loses her job. The battle for economic survival
turns intense and is now joined by disease. Acéphie dies of AIDS—loved
still by her own family but uncared for and unhelped by society. She
leaves behind a daughter, also infected with the virus. That is the begin-
ning of another story, but not a long one.

Foreword xv

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The inequalities of power that Acéphie faced in her brief life involved
bureaucracy (beginning with displacements to make room for the new
reservoir without adequate rearrangement), class (reflected in Acéphie’s
relations with her employer and with Captain Honorat), gender (related
to her standing vis-à-vis the males she encountered—from the soldiers
to Blanco), and of course the stratified society (with the absence of pub-
lic facilities for medical attention and care for the poor). Acéphie did not
encounter any physical violence, but Farmer is persuasive in seeing her
as a victim of structural violence.

POVERTY, INEQUALITY, AND POWER

The asymmetry of power can indeed generate a kind of quiet brutality.
We know, of course, that power corrupts and absolute power corrupts
absolutely. But inequalities of power in general prevent the sharing of
different opportunities. They can devastate the lives of those who are far
removed from the levers of control. Even their own lives are dominated
by decisions taken by others. In one chapter after another, Paul Farmer
illustrates the diversity and reach—and also the calamitous conse-
quences—of structural violence. The basic theme and the theses become
firmly established through these disparate but ultimately blended ac-
counts. The whole draws on the parts, but firmly transcends them, in the
integrated understanding that Farmer advances.

That understanding also suggests lines of thinking about ways of rem-
edying the deprivations and the disparities. For example, if inequality of
power, in different forms, is central to deprivation and destitution, then
little sense can be made of the frequently aired and increasingly popular
slogan, “I am against poverty, but I am really not bothered by inequal-
ity.” That attempt at a putative dichotomy can be disputed from differ-
ent perspectives, for example, through an appreciation of the powerful
effects of social and economic inequality on the unfreedoms that the sub-
jugated experience.4 The proposal to distance inequality from poverty is
severely challenged by Farmer’s many-sided documentation of the im-
pact of inequality of power on the lives that the subjugated can live. This
diagnosis does not, of course, yield any instant solution of the problems;
but it does indicate the difficult—and often ignored—social and eco-
nomic issues that must be firmly faced to eliminate preventable morbid-
ity and escapable mortality.

We live in an age of science, technology, and economic affluence when,
as Farmer points out, we can, for the first time in history, deal effectively

xvi Foreword

Farmer_FM_i-xxiv 11/26/02 12:43 PM Page xvi

with the diseases that ravage humanity. And yet the reach of science and
of globalization has stopped short of bringing reasonable opportunity
for survival within the grasp of the deprived masses in our affluent world.
This is where the pathologies of power take their toll. As Farmer argues,
“Anyone who wishes to be considered humane has ample cause to con-
sider what it means to be sick and poor in the era of globalization and
scientific advancement.”

Depressing as Farmer’s case studies are, their overall message is con-
structive and optimistic. The solutions are by no means easy, but they
are not beyond the reach of our informed and resolute effort. This vol-
ume is a major contribution to the understanding that is needed for a
determined encounter. We must avoid being like the man, to quote Dry-
den again, who “trudged along unknowing what he sought, / And whis-
tled as he went for want of thought.” Paul Farmer teaches us how to
stop whistling and start thinking. We have reason to be grateful.

Foreword xvii

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Farmer_FM_i-xxiv 11/26/02 12:43 PM Page xviii

xix

ACKNOWLEDGMENTS

Because these chapters are grounded in the experience of specific com-
munities, I have many debts to people on three continents and on a cou-
ple of very special islands. In Haiti, I am, as ever, grateful to Didi Bertrand,
Fritz and Yolande Lafontant, Flora Chipps, and Loune Viaud as well as
to the people of Cange and to the large number of victims of human rights
abuses who came to me seeking my help as a physician. Several of my pa-
tients requested specifically that their stories be told; I hope they will for-
give the lag time. Of course, it takes a village to care for patients, and so
I would like to thank some of my colleagues—friends, really—in Haiti:
Fernet Léandre, Jean-Hughes Jérôme, Cynthia Orélus, Jessye Bertrand,
Marie-Sidonise Claude, Wesler Lambert, Maxi Raymonville, Maxcène
Oréus, Jean Germeille Ferrer, and other clinicians at the Clinique Bon
Sauveur. In Port-au-Prince, I am indebted to William Smarth, Antoine
Adrien, Michèle Pierre-Louis, Mildred Trouillot Aristide, and to all those
working for social and economic rights in Haiti. Thanks also to Hervé
Razafimbahiny and Brian Concannon (who, in addition to working on
major projects, are never too busy to help get innocent people out of jail),
as well as Michelle Karshan and the rest of the small human rights com-
munity in Haiti. They know that the path is paved with thorns.

In Cuba, I thank my great friend Jorge Pérez Ávila, who will forgive
me, I hope, for taking his patients out drinking (they were only mojitos).
I am also grateful to Gustavo Kourí, Jorge González Pérez, Guadalupe
Guzmán, and the community of those living in Santiago de las Vegas. In

Farmer_FM_i-xxiv 11/26/02 12:43 PM Page xix

addition, I add special thanks to Jesús Valle, Eduardo Campo, Fernando
Mederos, and others good enough to spend so much time recounting
their own experiences.

In Guatemala, I am especially obliged to Blanca Jiménez, Jesús Gas-
par Jerónimo, Juan Alberto Jiménez, and Santiago Pablo Diego. In spite
of their terrible losses during a war financed in part by my country of
origin, they have offered me nothing but hospitality and kindness. In
Mexico, deep appreciation goes to Julio Quiñones Hernández; Leonel
González Ortiz; Dagmar Castillo; Jorge Gabriel García Salyano, and all
of the staff of EAPSEC; Demóstenes Martín Pérez Urbina; Father Elib-
erto; and Pablo and Patricia Farías. Gratitude and admiration to the
valiant people of many different communities in the autonomous zones,
who, given current conditions, wisely prefer to go unnamed. The Fray
Bartolomé de Las Casas Human Rights Center is an invaluable source
of important documentation, and I am grateful for its hospitality.

In Russia, I thank Oksana Pomonarenko, Alexander Goldfarb, Eka-
terina Goncharova, Alexander Pasechnikov, and many others at both
Partners In Health–Russia and the Public Health Research Institute
(PHRI). Thanks also to Sergei Borisov, Mikhael Perelman, and other col-
leagues involved in the care of patients with tuberculosis. Valery
Sergeyev, regional director of the Moscow office of Penal Reform Inter-
national, has been a patient source of unbiased information. Within the
Ministry of Justice, I am grateful to Alexandr Kononets, Yuri I. Kalinin,
Vladimir Yu. Yalunin, and Minister Yuri Chayka. It has been striking to
me that I had readier access to prisons in Russia than I did in my own
country. All my trips to the Russian Federation were related, in one way
or another, to the Open Society Institute; and I thank my many inter-
locutors in New York and in Moscow, including George Soros, Mia
Nitchun, Srdjan Mati®, Nina Schwalbe, Nancy Mahon, Miriam Porter,
and Ekaterina Yurievna. Most of all, I thank Aryeh Neier, a visionary in
several realms, not the least of them human rights.

In Peru, I …

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