Sunday, May 27, 2012

Renouncing Paul Farmer: A Desperate Plea for Radical Political Medicine

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.  

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

[1] See PIH slogan and learn more about PIH history and philosophy at
[2] See more about the Global Health Delivery Project at
[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.