Everywhere there are people of goodwill who quite
honestly believe that they are working for the overthrow of class-distinctions.
The middle-class Socialist enthuses over the proletariat and runs 'summer schools'
[clinics?] where the proletarian and the repentant bourgeois are supposed to fall
upon one another's necks and be brothers [partners?] for ever; and the bourgeois visitors come away saying how wonderful
and inspiring it has all been (the proletarian ones come away saying something
different).
-George Orwell, ‘The Road to
Wigan Pier’, 1937
In my first year at Harvard Medical School (HMS) in 2008, Drs.
Paul Farmer and Jim Kim co-taught ‘Introduction to Social Medicine’ to all
first-year medical students. For those
not familiar with Farmer and Kim, they are prominent physician-anthropologists
who trained at Harvard and co-founded ‘Partners in Health’ (PIH), a
transnational organization which is “providing a preferential option for the
poor in health care.”[1] Most medical students interested in global
health and social medicine are, as I was, quite enamored with Partners in
Health, given its emphasis on providing quality healthcare to the ‘wretched of
the earth’, the global poor. Indeed,
their presence at Harvard was one of the main reasons I decided to attend
medical school there, as I too had/have ambitions of becoming a doctor
dedicated to global health.
I was initially tremendously excited about the ‘Introduction
to Social Medicine’ course. But it
turned out to be an enormous disappointment.
First, its level of engagement with the social determinants of
healthcare was (perhaps appropriate to a politically conservative institution
like HMS) superficial. We were taught
little more than the banal fact that poverty is a major etiology of
disease. Second, instead of being taught
careful methods of engaging with poverty as physicians, Jim Kim presented to
us, in conjunction with Michael Porter of Harvard Business School, ‘global health
delivery’ models, ways of using logistical tools of commercial production to
improve efficiency and efficacy of the ‘delivery’ of global health care.[2] Instead of urging us to engage in deeper scholarship
of history, anthropology, and philosophy, Kim – who later left to become
president of Dartmouth College, and now, tellingly, stands president-elect of
the World Bank – encouraged first-year HMS students to pursue MBAs.[3] Third, and most importantly for me, was a
fleeting conversation I had with a PIH-affiliated tutor in the course. At the time, I learned that the Sendero
Luminoso, a Maoist rebel group, had bombed a PIH clinic in Peru.[4] How, I wondered, could a Marxist group find
PIH objectionable? I knew that Farmer’s
own intellectual work was informed by the world-systems theory of Marxist
Immanuel Wallerstein, and that his personal beliefs were confluent with
liberation theology, a blend of socialism and Catholicism. Asking my tutor to explain what seemed to me
a confusing contradiction, I received a metaphorical shrug. Turning to Farmer’s own Infections and Inequalities (2001), I was dismayed to find the same
response:
Sendero’s analysis [of PIH as reformers in the
pejorative sense]…was less easy to dismiss.
We were patching up wounds. Such
interventions would not, it’s true, alter the overall trends [of poverty]
registered in the slums of Lima, settlements growing at a rapid rate. With a certain degree of angst, we continued
our modest attempts… (pg. 30)
This discomforting absence of rational explanation, this
will to act in the absence of self-critical thought, was in hindsight the
impetus for my own decision to enter graduate school in medical anthropology,
and also the beginning of my theoretical and practical renunciation of the
humanitarian approach of Paul Farmer.
After two years of reading radical philosophy and critical anthropology,
I recently came across Jeremy Weinstein’s Inside
Rebellion, a political science ethnography that, through interviews of
former rebels and rebel commanders, seeks to understand the logic of rebellion
from within insurgent groups. One of
Weinstein’s cases was that of the very same group – the Sendero Luminoso – that
bombed the PIH clinic. Let us put aside
discussions of whether the group genuinely embodies Maoist praxis, if its
violence is excessive and cruel[5],
if some of its factions’ involvement in narco-trafficking compromises its
revolutionary principles[6],
etc. These are no doubt discussions of
tremendous importance. But as I am more
interested in Farmer’s reading of the Sendero Luminoso, which seems largely
sympathetic, let us assume for our purposes that the Sendero Luminoso is a
revolutionary Maoist organization that, despite its various internal struggles,
genuinely seeks radical equality for the poorest indigenous groups in Peru,
even at the cost of political violence.
Weinstein’s historical tracing of the conflict between the Sendero
Luminoso and the government of Peru then provides an invaluable insight into
why the rebels might have bombed the PIH clinic. In the early 1990s, Weinstein explains, as an
explicit part of its counterinsurgency program, the Fujimori government began
building roads, schools, and health centers to reduce civilian support for the
insurgency. Among those military
officers involved in the counterinsurgency campaign was Ollanta Humala,
pictured below with PIH co-founder Jim Kim in April 2012, shortly after Kim’s
appointment as president-elect of World Bank.
 |
| Source: http://peru21.pe/2012/04/16/actualidad/electo-presidente-banco-mundial-se-reunio-ollanta-humala-2020371 |
This historical framing of the bombing of a PIH clinic in
Peru illuminates the paradoxical nature of Farmer’s oft-proclaimed
‘partnership’ with the poor and attention to the historical and political
dimensions of poverty and disease. When
his organization began work in slums around Lima in 1994, it was
historico-politically inserted into a counterrevolutionary government
policy. Where Farmer laments his own
inability to philosophically reconcile his practice of ‘patching up wounds’
with the revolutionary approach of the Sendero Luminoso[7],
his remarkably ahistorical account fails to grasp the very simple fact that,
all ideology aside, PIH was in practice directly – and seemingly naively, given
Farmer’s inattention to this fact – inserted into a reactionary campaign on
behalf of the Peruvian government. Yes,
they were delaying the radical transformation of Peruvian society in the
abstract, as Farmer assumed; but, to invoke the political history of oppression
which occupies a central part of Farmer’s anthropological methodology
(particularly in his work on Haiti), they were concretely aligning themselves with
the government against the Sendero Luminoso in what can, at best, be described
a inexperienced, ahistorical, and apolitical humanitarian intervention for ‘the
poor’.[8]
Increasingly, it seems, Partners in Health, that darling of
the American left (including many medical anthropologists) supported by
‘liberal communists’ such as Bill and Melinda Gates, has found itself trapped
in what Slavoj Žižek has called the “liberal trap of ‘humanitarian help’”. Despite being left-of-center and claiming
partnership with the poor, it is increasingly finding the apolitical float of
‘humanity’ and ‘human rights’ on which it perilously balances melting below its
feet. Just last month, in Belladere,
Haiti, Partners in Health/Zanmi Lasante staff were targeted by arson and other
attacks. A ZL healthworker died in the
fire, and other ZL workers and their family members were injured. According to a PIH worker with whom I
recently spoke, this attack was orchestrated in response to the actions of a
PIH/ZL worker who sought to connect the good image (or symbolic capital) of the
organization’s work to an electoral candidate’s campaign. In a statement released on their website, PIH
naively proclaims:
…we urge partisans to respect the neutrality of PIH
and ZL in the political process…In advocating for access to free services for
the poorest and most vulnerable communities in Haiti, PIH and ZL work with the
Government of Haiti to strengthen the public health care sector, in close
partnership with affected communities and other local partners. While we work
with democratically-elected officials and their appointed officials of the
government, PIH/ZL neither participates in the electoral process, nor
affiliates with any political party. Despite the recent acts of violence that
have occurred, we remain committed to serving our communities in an impartial
manner. (PIH
Statement: Political Violence in Belladere)
The Ethical Turn of
1968
Of course, there is no such thing as neutrality or
impartiality in humanitarianism. Didier
Fassin, a fellow physician-anthropologist and former vice president of Doctors
without Borders (MSF), has repeatedly stressed how contemporary humanitarians
shift attention from the causes of violence to its consequences in a way that
replaces a politics of justice with a politics of compassion – in essence,
refuses politics for ethics. Humanitarians,
he argues, operate on an inequality of life and a hierarchy of humanity,
aspiring to moral untouchability while avoiding a ‘parrhesia’ – a truth that,
once told, can incur a high cost for the teller himself. For humanitarians, this truth is precisely
that humanitarian interventions are always political. They are guided, as Peter Redfield (citing Renée
Fox) points
out, by a ‘non-ideological ideology’ – that is, an ideology that refuses to
recognize itself as such. When PIH
insists that all life, especially the poor’s, is worth saving, it partakes in a
negative form of politics that denies the selective reality of its political
practices, including questions of sacrifice and triage. In Peru, it stood with the government against
the Sendero Luminoso; by accepting funding from Bill Gates, it stands politically
together with the notion that a ruthless pursuit of profit can be counteracted
by charity.
Farmer and Kim are, no doubt, embodiments of the dark side
of the spirit of 1968. In the face of
increasing poverty and a new, flexible capitalism, the protests of 1968
belonged, Luc Boltanski and Eve Chiapello argue[9],
to one of two basic categories: cultural-artistic or social. Examining these protests in France, they
observed that the cultural-artistic critiques of capitalism (by students,
against the alienating and dehumanizing aspects of capitalism) won out over the
social critiques (by workers, against the exploitation of capitalism). Some of those same protestors later took up
government posts and corporate jobs, transforming wage labor into a more
personal, humane, and anti-authoritarian experience without challenging the
capitalist mode of production itself.
Instead of dismantling capitalist relations of production, they
bargained for a more palatable form, and with it, left behind the language of
‘exploitation’ and ‘inequality’ for ‘exclusion’. The term ‘excluded’, as Boltanski and
Chiapello argue, refuses accusation or denunciation. Instead of pointing to the causes of
exploitation, it regresses to mere indignation at suffering. In the humanitarian sphere, this resulted in
an epochal shift[10]:
where humanitarian action had previously been condemned as a hypocritical
diversion from political action, it became the preferred mode of acting on
suffering. Concretely, as Fassin has
noted[11],
this meant that privileged volunteers no longer went off to fight alongside
people in their liberation struggles, in the political name of revolution;
instead, they became professionalized aid workers who went to take care of
people in the ethical name of human rights or psychiatric harm.
Politics has become a matter of ethics, and Partners in
Health is deeply embedded within this historical turn as it claims ‘neutrality’
and ‘impartiality’. Indeed, ‘structural
violence’, the very phrase which Farmer has popularized (itself introduced by
Johan Galtung in – tellingly – 1969), is precisely so powerful and widespread because
it substitutes indignation for accusation.
As Loïc Wacquant implies in his critique of Farmer, the concept of
‘structural violence’ timidly eschews assigning any agency for this violence,
which becomes - in Farmer’s own words - “ostensibly ‘nobody’s fault’ ”. It is precisely in this turn that the
parrhesia is avoided, the danger of self-exposure averted. In the rhetoric of being a ‘partner’ to the
poor, the realities of class analysis fall softly but fatally out of Farmer’s
theory and work. An elite, bourgeois
group of doctors, activists, and donors help the poor out of moral sentiment[12],
refusing or erasing their own class responsibility in what Marx rightly called
out as ‘conservative, or bourgeois, socialism’:
A part of the bourgeoisie is desirous of redressing
social grievances in order to secure the continued existence of bourgeois
society…To this section belong economists, philanthropists, humanitarians,
improvers of the condition of the working class, organisers of charity, members
of societies for the prevention of cruelty to animals, temperance fanatics,
hole-and-corner reformers of every imaginable kind…The Socialistic bourgeois
want all the advantages of modern social conditions without the struggles and
dangers necessarily resulting therefrom. They desire the existing state of
society, minus its revolutionary and disintegrating elements. They wish for a
bourgeoisie without a proletariat.
-Karl
Marx, ‘The Communist Manifesto’, 1848
The Critique of
Liberalism: Where has the Enemy gone?
If PIH refuses politics in favor of ethics on the thin,
melting ice of ‘humanity’ and ‘human rights’, it does so, Carl Schmitt would
argue, at the risk of entering into the perilous domain of liberalism. Liberalism, Schmitt wrote in 1932, had
introduced an age of ‘depoliticizations’, negating the political while really
only hiding it. Liberalism is, he points
out, an intellectually inconsistent idea that evades or ignores the State and
politics in favor of the ethico-ideological conception of ‘humanity’. Indeed, when man ceases to be political,
Schmitt argues, he ceases to be human. To claim ‘humanity’ is to deny the
possibility of an enemy, or at least, to recreate that enemy as inhuman (one
only has to think of today’s militarized humanitarian discourse and practice about
‘terrorists’ eliminated[13]
by unmanned drones). For Schmitt, the
concept of humanity was used as an ideological instrument of imperialist
expansion, an ethical-humanitarian form that promoted economic
imperialism. Providing what remains
today a useful defense of politics over ethics, Schmitt insists that the distinction
of friend-enemy persists even if ethics dominates politics; it merely hides in
the shadows, repressed by liberal thought.
For PIH, the poor of Peru, Boston, Haiti, and countless other
sites is the ‘friend’. But, for an
organization whose theoretical foundation is so intensely humanist, faceless
‘structures’ automatically become the enemy.
For Farmer, it is the inhuman structural adjustment policies and the lifeless
imperialist doctrines that oppose humanity.
Not Bill Gates, whose donations to PIH seem to ‘cancel out’ the over $60
billion worth of capital he has extracted from the poor.[14] Nor PIH’s own Director of Corporate and
Foundation Relations, whose naivety facilitates the co-optation, as Žižek suggests,
of the Porto Alegre’s World Social Forum by Davos’s World Economic Forum, who
lets (both ideologically and practically) liberal communists give back a little
in the afternoon of what they brutally stole in the morning. Nor, most importantly, those bourgeois ‘partners’
in health themselves, who – with, let there be no doubt, great existential
angst[15]
- ignore the problem of class through the contradictory humanist philosophy of
liberation theology.
Toward a Radical Political Medicine Yet-to-Come: In Memory
and Spirit of Dr. Norman Bethune
The fact that has got to be faced is that to abolish
class-distinctions means abolishing a part of yourself. Here am I, a typical
member of the middle class. It is easy for me to say that I want to get rid of
class-distinctions, but nearly everything I think and do is a result of
class-distinctions…I have got to alter myself so completely that at the end I
should hardly be recognizable as the same person.
-Orwell, ‘The Road to Wigan
Pier’, 1937
If Farmer’s approach to the health of the poor is naively
humanist at best and actively oppressive at worst, if it refuses politics for
ethics, if it claims no human enemy, and works hand-in-hand with capital, then
where can or should progressive medicine move?
One starting point is to revive the memory of a now-forgotten
predecessor to Paul Farmer, a truer ‘partner’ to the poor – the Canadian
surgeon Dr. Norman Bethune.[16] Bethune (1890-1939), like Farmer, refused a
resigned approach to what was broadly perceived to be incurable
tuberculosis. Infected with TB and
confined to a sanatorium where he expected to die, Bethune pursued a then
academically suspect form of treatment (induced traumatic pneumothorax[17])
and made a seemingly miraculous recovery.
His life restored, he became interested in the socioeconomic
determinants of health, advocating socialized medicine and developing an
interest in communism. As he became more
politically aware, he joined the anti-fascist forces in the Spanish Civil War
as well as the Chinese communists in their battle against Japanese
imperialists. Although not actively
involved in political leadership and strategy, Bethune became a doctor on the
frontlines, developing mobile blood transfusion units that saved the lives of
soldiers at the battlefront who had hitherto been dying of blood loss, unable
to reach distant clinics before death caught them. Make no mistake – Bethune was not interested
in ‘humanity’ or the ‘structures’ that killed it. Instead of practicing medicine in the
abstract, apolitical service of the ‘poor’, he was saving the lives of soldiers
who were fighting political wars against imperialism and fascism. Although he also treated Japanese POWs, he effectively
applied his medical skills and developed medical innovations in service of politics,
not ‘impartial’ and ‘neutral’ ethics; to save the men and women fighting the
political enemy, not abstract ‘humanity’ or the ‘poor’.
In the memory and spirit of Bethune, we urgently need to
move beyond the liberal communist approach to medicine made so popular by Paul
Farmer. In attempting to revive Bethune
as an alternative idol for the medical Left, I desperately plea for a more
radical and explicitly politicized medicine yet-to-come. What could this medicine look like? It certainly will not be one based on human
rights, humanity, or humanism of any simple kind. It cannot hypocritically undercut radical
attempts to revolutionize the ‘structure’ committing ‘structural violence’. Nor will it follow Farmer’s bourgeois
socialism that maintains a bourgeoisie without a proletariat. Indeed, it will require tremendous
self-sacrifice and – more importantly – constant self-criticism and selective
self-destruction to weed out the class-distinctions of doctors and activists
who advocate for the poor. In the spirit
of Orwell (cited above), not only medicine but also its practitioners
(including myself and my HMS classmates) will be radically transformed, so
drastically altered as to “hardly be recognizable as the same person.”
As Subcomandante Marcos of the Zapatista movement has put it
bluntly, “We are all human beings, but some are sons of bitches, and some
aren’t. That is the truth.” As rational, progressive physicians, we
cannot be afraid of this truth, nor timid of its consequences – especially for
our own lives, sentiments, fragilities, and inconveniences. Let us abandon the contradictory liberalism
and love of ‘humanity’ to which we so desperately cling in self-deluded
self-preservation, and embrace the political domain to which, no matter how hard we
try to deny or avoid, we inevitably and integrally belong.
Last edited June 5, 2012
Last edited June 5, 2012
[1]
See PIH slogan and learn more about PIH history and philosophy at http://www.pih.org/.
[2]
See more about the Global Health Delivery Project at http://globalhealthdelivery.org/.
[3]
My classmates eagerly obliged; tens of them are pursuing joint MD-MBAs at HMS
and HBS, although Kim’s influence was likely not determining in many
cases.
[4]
In Peru, Partners in Health is known as Socios
en Salud.
[5]
Farmer, incidentally, calls Sendero violence ‘arbitrary’, a designation that
any political scientist or scholar of political violence knows to be shoddy
scholarship at best and ideologically-driven at worst. See, for example, Stathis Kalyvas’s ‘The
Logic of Violence in Civil War’ (2006).
[6]
In particular, the Comité Regional del Huallaga is said to rely on coca production
as its dominant source of funding, and to have over time grown less attentive
to and less guided by the revolutionary ideology of the central committee.
[7]
Farmer’s
silence here is adeptly filled by Slavoj Žižek: “…when Sendero Luminoso took over a village, they
did not focus on killing the soldiers or policemen stationed there, but more on
the UN or U.S. agricultural consultants or health workers trying to help the
local peasants—after lecturing them for hours and then forcing them to confess
publicly their complicity with imperialism, the Sendero Luminoso shot them.
Brutal as this procedure was, it was sustained by the correct insight: they,
not the police or the army, were the true danger, the enemy at its most
perfidious, since they were ‘‘lying in the guise of truth’’—the more they were
‘‘innocent’’ (they ‘‘really’’ tried to help the peasants), the more they served
as a tool of the United States. It is only such a strike against the enemy at
his best, at the point where the enemy ‘‘indeed helps us,’’ that displays a
true revolutionary autonomy and ‘‘sovereignty’’ (to use this term in its
Bataillean meaning). If one adopts the attitude of ‘‘let us take from the enemy
what is good and reject or even fight against what is bad,’’ one is already
caught in the liberal trap of ‘humanitarian help.’” (Žižek, ‘From Politics to Biopolitics…And Back’,
2004, pgs. 512-513)
[8]
In mistaking a politico-historically situated act for a purely ideological act,
Farmer says, “A couple of years earlier, a Sendero communiqué had ordered
nongovernmental organizations out of Peru because ‘you give crumbs to the
people to entertain them and fail to realize that the correct path is that of
the people’s war’” (Infections and Inequalities,
2001, pg. 30). This reference to Sendero
ideology is precisely the problem with Farmer’s approach: he cites (in footnote
23) reports from 1984, 1986, and 1989 – a full five years before his own
organization’s insertion in the midst of a dynamic guerrilla warfare campaign
and before the Fujimori government began to use clinics, schools, etc. as a
tactic of reducing support for the Sendero.
It is astounding that his account makes no mention of this practical complicity
with the corrupt Fujimori government. In
2009, Fujimori was sentenced to 25 years in prison for ‘human rights abuses’
committed in a 1991 massacre during the counterinsurgency campaign.
[9]
See ‘The New Spirit of Capitalism’ (published in French in 1999; in English in
2005)
[10]
And, in the Foucaultian sense, an epistemic
shift
[11]
See his 2008 article, ‘The Humanitarian Politics of Testimony’, published in Cultural Anthropology.
[12]
A sentiment that recognizes the suffering imposed by capitalism, without
thoroughly investigating the logic of that mode of production or its own
positionality within it.
[13]
The word choice of ‘eliminate’ instead of ‘kill’ should be evident: one cannot
kill the ‘terrorist’ because he is already inhuman. He can only be eliminated, removed, destroyed.
[14]
I do not have space here to explain Marx’s theory of surplus value, or his
(along with Smith and Ricardo’s) conception that wealth is derived primarily
from labor. Refer especially to Chs. 4-6
of Marx’s ‘Capital, Volume 1’.
[15]
I am currently working on a brief essay exploring this bourgeois angst, which
will be posted on this blog in the near future.
[16]
For those interested in reading more about Dr. Bethune, I would recommend Allen
and Gordon’s “The Scalpel, the Sword: The Story of Doctor Norman Bethune” as
well as Stewart’s “The Mind of Norman Bethune”.
Mao’s ‘In
Memory of Norman Bethune’ (to which this section’s title alludes) offers a
warm obituary following Bethune’s death in 1939.
[17]
Of course, this was prior to the discovery of now first-line antimycobacterial
drugs such as isoniazid or rifampin, developed in or after the 1950s.
