Partner to the Poor

Partner to the Poor: A Paul Farmer Reader

Edited by Haun Saussy
Foreword by Tracy Kidder
Copyright Date: 2010
Edition: 1
Pages: 680
https://www.jstor.org/stable/10.1525/j.ctt1ppcmr
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  • Book Info
    Partner to the Poor
    Book Description:

    For nearly thirty years, anthropologist and physician Paul Farmer has traveled to some of the most impoverished places on earth to bring comfort and the best possible medical care to the poorest of the poor. Driven by his stated intent to "make human rights substantial," Farmer has treated patients-and worked to address the root causes of their disease-in Haiti, Boston, Peru, Rwanda, and elsewhere in the developing world. In 1987, with several colleagues, he founded Partners In Health to provide a preferential option for the poor in health care. Throughout his career, Farmer has written eloquently and extensively on these efforts.Partner to the Poorcollects his writings from 1988 to 2009 on anthropology, epidemiology, health care for the global poor, and international public health policy, providing a broad overview of his work. It illuminates the depth and impact of Farmer's contributions and demonstrates how, over time, this unassuming and dedicated doctor has fundamentally changed the way we think about health, international aid, and social justice. A portion of the proceeds from the sale of this book will be donated to Partners In Health.

    eISBN: 978-0-520-94563-0
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-iv)
  2. Table of Contents
    (pp. v-viii)
  3. Foreword: Seeing the Proof
    (pp. ix-xii)
    Tracy Kidder

    A few years back I wrote a book calledMountains Beyond Mountains.It has a subtitle: “The Quest of Dr. Paul Farmer, a Man Who Would Cure the World.” I don’t much like subtitles and I didn’t add this one willingly, but I suppose it’s accurate enough. My book is mostly about one person, Paul Farmer, and, as we all know, the old saw that one person can make a difference in this world really isn’t the whole truth. Paul Farmer never wanted me to imagine that he alone was responsible for the early work of Partners In Health. In...

  4. Introduction: The Right to Claim Rights
    (pp. 1-24)
    Haun Saussy

    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—but the essential thing about him is that he listens to his patients.

    In the earliest piece of writing collected here (“Bad Blood, Spoiled Milk,” from 1988), the young Paul Farmer, anthropologist, epidemiologist, doctor to the poor, gives an informant the last word:

    I consulted [Madame Gracia] regarding the ingredients of the herbal remedy formove san/lèt gate.Her response, and the tone in which it was delivered, brought me up short: “Surely you...

  5. PART 1. ETHNOGRAPHY, HISTORY, POLITICAL ECONOMY
    • Introduction to Part 1
      (pp. 27-32)
      Paul Farmer

      In rereading the studies and essays collected in this book—some of them published while I was still in graduate school, some of them quite recent and published here for the first time, the majority from the years in between—I discern trends different from the ones I had expected, even hoped for. After more than two decades of writing for peers in anthropology and medicine, one hopes to be impressed by (or at least to note) a steady improvement in the quality of writing, or by ever more thorough exploration of the implications of findings, or by the depths...

    • 1 Bad Blood, Spoiled Milk: Bodily Fluids as Moral Barometers in Rural Haiti (1988)
      (pp. 33-61)

      Current discourse in medical anthropology is marked by an increasing appreciation of the body as physical, social, and political artifact. Concepts such as somatization, which implies the making corporeal of nonbodily experience, are by now common coin, and there is considerable enthusiasm for the increasingly fine-grained analyses that appear in several new specialty journals. But others discern an overweening analytic urge that yields fragmentary knowledge resistant to synthesis. Illness experiences are picked apart under the dissecting gaze not only of biomedicine but of anthropology as well, a discipline long parsed into such officially sanctioned subfields as “psychological” and “biological” anthropologies....

    • 2 Sending Sickness: Sorcery, Politics, and Changing Concepts of AIDS in Rural Haiti (1990)
      (pp. 62-93)

      AIDS presents new challenges to medical anthropology. Some are theoretical and not substantially different from the challenges faced by other ethnographers who seek to study, comprehend, and describe new phenomena. Others involve the ethical dilemmas inherent both in the study of a terrible new affliction for which (at the time of this writing) we have only limited therapeutic recourse and in the deeply vexed question of how anthropologists might best contribute to the effort to prevent transmission of HIV. What follows is a processual ethnography of the advent of AIDS in Do Kay, a small village in Haiti’s Central Plateau....

    • 3 The Exotic and the Mundane: Human Immunodeficiency Virus in Haiti (1990)
      (pp. 94-120)

      Early in the pandemic of the acquired immune deficiency syndrome (AIDS), a number of Haitians fell ill with opportunistic infections characteristic of the new syndrome. Some of the ill Haitians lived in urban Haiti; others had emigrated to the United States or Canada. Unlike other patients who met the diagnostic criteria for AIDS, the Haitians diagnosed in the United States denied having participated in homosexual activity or intravenous drug use. Most had never had a blood transfusion. AIDS among Haitians was, in the words of many researchers, “a complete mystery.” Public health officials therefore inferred that Haitians per se were...

    • 4 Ethnography, Social Analysis, and the Prevention of Sexually Transmitted HIV Infection among Poor Women in Haiti (1997)
      (pp. 121-135)

      Social scientists and physicians alike have long known that the socioeconomically disadvantaged have higher rates of disease than those not hampered by such constraints. But what are the mechanisms and processes that transform social factors into personal risk? How do forces as disparate as sexism, poverty, and political violence become embodied as individual pathology? These and related questions are key not only to medical anthropology but to social theory in general.

      These questions are posed acutely in considering HIV infection, now that AIDS has become a leading cause of death among young adults throughout the world. As HIV advances, it...

    • 5 From Haiti to Rwanda: AIDS and Accusations (2006)
      (pp. 136-148)

      AIDS and Accusation,published in 1992, summarized a number of lessons gleaned from my fieldwork, research, and clinical practice. First, I learned that AIDS, although a new disease, is deeply embedded in social and economic structures long in place—and that poverty and inequality are the fault lines along which HIV spreads. Even when I wrote the book, those of us working with the disease saw that AIDS was likely to become a major killer of people living in poverty.

      I also learned how medical errors, bad diagnoses, and confidently expressed but incorrect claims of causality could themselves cause great...

  6. PART 2. ANTHROPOLOGY AMID EPIDEMICS
    • Introduction to Part 2
      (pp. 151-154)
      Paul Farmer

      This part of the book groups a second set of (sometimes yeomanlike) studies and essays under the rubric “Anthropology amid Epidemics.” The first of these essays builds on lessons learned: that large-scale social forces are what drive forward epidemic diseases, and that this is just as true of what have been called “social diseases” (tuberculosis, for example, and what were once termed “venereal diseases”) as it is of, say, dengue or typhus or even Ebola. Sometimes these largely economic considerations are referred to as structural forces. That structural forces are the motive power behind contagious disease is obvious to historians...

    • 6 Rethinking “Emerging Infectious Diseases” (1996, 1999)
      (pp. 155-173)

      AIDS. Ebola. Flesh-eating bacteria. One of the most significant events of the past ten or fifteen years is the explosion of “emerging infectious diseases.” Some of these disorders—such as AIDS and Brazilian purpuric fever—can be regarded as genuinely new. Others were clinically identified some time ago but have newly identified etiologic agents or have again burst onto the scene in dramatic fashion. For example, the syndromes caused by Hantaan viruses have been known in Asia for centuries, but they now seem to be spreading beyond that continent as a result of ecological and economic transformations that increase contact...

    • 7 Social Scientists and the New Tuberculosis (1997)
      (pp. 174-194)

      “It seems almost incredible that during this century and the previous one, a single disease, tuberculosis, was responsible for the deaths of approximately a thousand million human beings.”¹ So wrote Frank Ryan, looking back in the late twentieth century on the history of efforts to combat that disease. Almost simultaneously, a 1992 review of the world epidemiology of tuberculosis concluded that the disease remained the leading infectious cause of preventable deaths in the world.²

      Even in some of the fortunate nations where TB mortality had steadily decreased throughout most of the twentieth century, these trends have been reversed. In the...

    • 8 Optimism and Pessimism in Tuberculosis Control: Lessons from Rural Haiti (1999)
      (pp. 195-205)

      A survey of the current literature reveals discordant views on the question of progress in the control of tuberculosis. On the one hand, optimistic observers point with understandable pride to advances in our understanding of mycobacterial pathogenesis and to the elaboration of shorter but more effective treatment regimens. Recent years have seen a growing consensus that even six-month-long, multidrug regimens will lead to high cure rates if therapy is directly observed by medical personnel or health workers. The World Health Organization’s adoption of DOTS—directly observed therapy, short-course—has been hailed as a victory by experts from around the world.¹...

    • 9 Cruel and Unusual: Drug-Resistant Tuberculosis as Punishment (1999)
      (pp. 206-221)

      The long and grim history of punishment records many inventive ways of making prisoners suffer. The crudest of these are usually known as penal torture, a practice roundly condemned by all governments—and practiced, nonetheless, by many. This essay addresses the issue oftuberculosis as punishment.

      Tuberculosis has a long history of association with prisons. In the pre-chemotherapeutic era, “consumption” was in many settings the major cause of prison mortality. In the mid-nineteenth century, for example, TB was estimated to have caused up to 80 percent of all U.S. prison deaths: in Boston, Philadelphia, and New York, in any case,...

    • 10 The Consumption of the Poor: Tuberculosis in the Twenty-First Century (2000)
      (pp. 222-247)

      The World Health Organization recently announced that in 1999 alone nearly two million persons died of tuberculosis.¹ Not since the turn of the century, when tuberculosis was the leading cause of young adult deaths in most U.S. cities, has the disease claimed so many lives. Tuberculosis, we are told, has returned “with a vengeance.”² In the language of the day, it is an “emerging infectious disease.” In scientific publications and in the popular press, the refrain is the same: tuberculosis, nce vanquished, is now resurging to trouble us once again.

      Yet tuberculosis has been with us all along; only from...

    • 11 Social Medicine and the Challenge of Biosocial Research (2000)
      (pp. 248-265)

      This essay examines social medicine as a necessarily interdisciplinary enterprise. It draws on examples from clinical practice in the area of infectious diseases and also from my work as an anthropologist seeking to understand the ways in which culture determines how health problems are construed as solvable or intractable. But this is neither a clinical review nor an ethnographic study; instead, I want to address a couple of vexing medical problems from a sociology-of-science point of view.¹ That is, I will look at the rise of antibiotic-resistant microbes—indisputably a biological process with social roots—and then examine critically a...

    • 12 The Major Infectious Diseases in the World—To Treat or Not to Treat? (2001)
      (pp. 266-269)

      In the July 2001 issue of theNew England Journal of Medicine,Kemal Tahaoğlu and coworkers report on their experience in treating a cohort of patients infected with strains ofMycobacterium tuberculosisthat are resistant to powerful antituberculosis drugs. Tuberculosis caused by strains that are resistant to at least isoniazid and rifampin is, by convention, termed “multidrug-resistant tuberculosis.”¹ The authors of this report work in a referral center in Turkey that has available a full complement of clinical, laboratory, and surgical services, including multidrug treatment regimens given for eighteen to twenty-four months, resources for the management of side effects, adjuvant...

    • 13 Integrated HIV Prevention and Care Strengthens Primary Health Care: Lessons from Rural Haiti (2004)
      (pp. 270-286)
      David A. Walton, Paul Farmer, Wesler Lambert, Fernet Léandre, Serena P. Koenig and Joia S. Mukherjee

      The Declaration of Alma-Ata, signed by World Health Organization member states in 1978, constitutes a major milestone in the contemporary primary health care movement. The goal was lofty—“health care for all by the year 2000”—and close attention was paid to the specific means by which that goal might be reached.¹ The plans that emerged from the meeting—from improved vaccination coverage to decreased malnutrition—were deemed feasible by the signatories. Yet these objectives have not been met in many of the very countries where such victories were most needed. Worse, the promotion of health care as a right...

    • 14 AIDS in 2006—Moving toward One World, One Hope? (2006)
      (pp. 287-290)
      Jim Yong Kim and Paul Farmer

      For the past two decades, AIDS experts—clinicians, epidemiologists, policymakers, activists, and scientists—have gathered every two years to confer about what is now the world’s leading infectious cause of death among young adults. This year, the International AIDS Society is hosting the meeting in Toronto from August 13 through 18. The last time the conference was held in Canada, in 1996, its theme was “One World, One Hope.” But it was evident to conferees from the poorer reaches of the world that the price tag of the era’s great hope—combination antiretroviral therapy—rendered it out of their reach....

  7. PART 3. STRUCTURAL VIOLENCE
    • Introduction to Part 3
      (pp. 293-297)
      Paul Farmer

      Part 3, “Structural Violence,” stems from an abiding interest in (possibly an obsession with) the ways in which epic poverty and inequality, with their deep histories, become embodied and experienced as violence. With Haiti in mind, it’s easy to see that socioeconomic processes, such as the entrenchment of chattel slavery in the eighteenth and nineteenth centuries and the violent responses to it, are still experienced as violence by those most affected, well after the lash is gone.

      Thus would the Haitians cited in these pages assure me that Haiti’s everyday travails during the late twentieth century were the direct result...

    • 15 Women, Poverty, and AIDS (1996)
      (pp. 298-327)

      AIDS was first recognized as a distinct physical syndrome in the summer of 1981, when physicians in California and New York noted clusterings of unusual infections and cancers in their patients. All of these patients were young, gay men, a group not previously known to have such opportunistic infections. In August, a mere two months after the first cases were reported in men, the same syndrome was identified in a woman.¹ Within a year, AIDS cases were registered among men and women who injected drugs, among hemophiliacs and some of their sexual partners, and among women and men from poor...

    • 16 On Suffering and Structural Violence: Social and Economic Rights in the Global Era (1996, 2003)
      (pp. 328-349)

      Everyone knows that suffering, violence, and misery exist. How to define them? Given that each person’s pain has for him or her a degree of reality that the pain of others can surely never approach, is widespread agreement on the subject possible? And yet people do agree, as often as not, on what constitutes extreme suffering: premature and painful illnesses, say, as well as torture and rape. More insidious assaults on dignity, such as institutionalized racism and gender inequality, are also acknowledged by most to cause great and unjust injury.

      So suffering is a fact. Now a number of corollary...

    • 17 An Anthropology of Structural Violence (2001, 2004)
      (pp. 350-375)

      The ethnographically visible, central Haiti, September 2000:Most hospitals in the region are empty. This is not because of a local lack of treatable pathology; rather, patients have no money to pay for care. But one hospital—situated in a squatter settlement just 8 kilometers from a hydroelectric dam that decades ago flooded a fertile valley—is crowded. Medicines and laboratory studies are free. Every bed is filled, and the courtyard in front of the clinic is mobbed with patients waiting to be seen. Over a hundred slept on the grounds last night and are now struggling to smooth out...

    • 18 Structural Violence and Clinical Medicine (2006)
      (pp. 376-392)
      Paul Farmer, Bruce Nizeye, Sara Stulac and Salmaan Keshavjee

      Because of our contact with patients, physicians readily appreciate that largescale social forces—racism, gender inequality, poverty, political violence, and war, and sometimes the very policies that address them—often determine who falls ill and who has access to care. For practitioners of public health, the social determinants of disease are even harder to disregard.

      Unfortunately, this awareness is seldom translated into formal analytic frameworks that link social analysis to everyday clinical practice. One reason for this gap is that the holy grail of modern medicine remains the search for the molecular basis of disease. While the practical yield of...

    • 19 Mother Courage and the Costs of War (2008)
      (pp. 393-408)

      War is good for something, or someone, or it would not have persisted for millennia as a major staple of human interaction. War pays, goes the old saw. But what are the wages of war? Whom does it pay, and who pays for it? How does it pay? Most important, what are the real costs of war and conflict? My guess is that Bertolt Brecht wrote his famous playMother Couragein order to ask and answer some of these questions. And the answers are revealed, over time, to his unlikely protagonist, a Swedish market woman and mother seeking to...

    • 20 “Landmine Boy” and Stupid Deaths (2008)
      (pp. 409-426)

      I have been working in Haiti all of my adult life and in Rwanda since 2005. In Rwanda, I work predominantly as a physician rather than as an anthropologist conducting ethnographic fieldwork. Ethnographers of this region know the language, culture, and history of Rwanda far better than I do. If I spoke Kinyarwanda fluently and had spent many years in Rwanda, perhaps I might claim the ethnographer’s privilege of systematic knowledge or offer to decipher, as many of my colleagues do, the symbolics or poetics of violence.¹ But work in Haiti and elsewhere in Latin America has given me rough-and-ready...

  8. PART 4. HUMAN RIGHTS AND A CRITIQUE OF MEDICAL ETHICS
    • Introduction to Part 4
      (pp. 429-434)
      Paul Farmer

      The fourth part of this book offers critical reflections on human rights regimes and on narrowly defined bioethics. To say “regimes” (or even “narrowly defined”) is to invoke, again, a sociology-of-knowledge perspective like that of Peter Berger and Thomas Luckmann (quoted at the opening of chapter 11).¹ For years, I failed to apply this perspective to human rights and medical ethics. To be frank, I simply assumed such topics to be above reproach. As a student and as a young physician, I spent many years unaware that there were competing rights agendas. Human rights struck me as a generally decent...

    • 21 Rethinking Health and Human Rights: Time for a Paradigm Shift (1999, 2003)
      (pp. 435-470)

      Medicine and its allied health sciences have for too long been only peripherally involved in work on human rights. Fifty years ago, the door to greater involvement was opened by Article 25 of the Universal Declaration of Human Rights, which underlined social and economic rights: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond...

    • 22 Rethinking Medical Ethics: A View from Below (2004)
      (pp. 471-486)
      Paul Farmer and Nicole Gastineau Campos

      Bioethics and medical ethics are necessarily contentious enterprises. These fields have the potential to embrace not only empiric research but philosophical commentary, informed opinion, and essay as well. The best scholarship in these related fields often addresses “unresolved issues” of moral conflict. Some issues are unresolved because they stem from novel developments, such as xenotransplantation or the latest in stem cell research; other issues are unresolved because too little attention has been paid to them in recent decades, in part because the discipline of medical ethics has arisen in certain social contexts and not in others. We argue here that...

    • 23 Never Again? Reflections on Human Values and Human Rights (2005)
      (pp. 487-527)

      A lecture on human values? Since all humans have values, to claim expertise in the universal arena of value-making is necessarily a perilous activity. Arguments abound. Are some values truly universal, the products of growing up in a human body and within a human family of some sort or another? Or are all human values socially constructed, with no real bedrock but what we create through culture? Aren’t all values by definition human? Many ethologists and sociobiologists dispute this last point fiercely.

      I would like to consider a small aspect of these issues: how photographs and stories may be used...

    • 24 Rich World, Poor World: Medical Ethics and Global Inequality (2006)
      (pp. 528-544)

      Allow me to begin, as philosophers so often have, by considering an altogether hypothetical situation. Let’s say we’re in a First World medical school. Let’s add, merely for the sake of argument, of course, that it’s a very large medical school in the Northeast of the United States—in fact, the world’s largest medical school, in terms of wealth and prestige; pronouncements from its faculty have considerable weight. Allow me to proceed as if I myself were on the faculty of said school and perhaps even, to round out the argument, an alumnus who for years has been able to...

    • 25 Making Human Rights Substantial (2008)
      (pp. 545-560)

      Since I’ve recently been working in Malawi, where maternal mortality is said to be the third highest in the world and where hunger and other afflictions abound, I’ll cite a recent essay by an expert on the country: “The tenets of liberalism in both politics and economy are now shared by all the political parties [in Malawi]. . . . Everybody, it seems, is committed to multiparty democracy, human rights, and the market economy.”¹

      How are democracy, human rights, and a “market economy” linked together? Are they so linked for the poor in particular? Amartya Sen, among others, has offered...

  9. Conclusion: An Interview (2009)
    (pp. 561-576)

    HAUN SAUSSY: Paul, from a beginning in ethnography, with its emphasis on the local, the specific, and the directly observed, you have gone on to offer accounts of what goes wrong with the whole human species in its many social subdivisions: ideas about “structural violence,” inventories of the horrors of war. The categories you operate with on this level seem even broader than the kinds of interactions you were observing at work in the local, specific connections that were the subject of your earliest published writing—namely, the relation between Haiti and its powerful neighbor, the United States, over a...

  10. ACKNOWLEDGMENTS
    (pp. 577-578)
    Paul Farmer and Haun Saussy
  11. WORKS CITED
    (pp. 579-638)
  12. EDITORIAL NOTE AND CREDITS
    (pp. 639-642)
  13. INDEX
    (pp. 643-660)
  14. Back Matter
    (pp. 661-664)