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. 


  1. Very interesting post....With the hindsight of history and given the negative impact Sendero's strategies had on many peasant communities caught in-between a repressive government and an extremely dogmatic revolutionary group -- I have a hard time putting aside the caveats you note re: Sendero Luminoso. THAT SAID, your points about "politics" and the ideological sleight-of-hand that occurs when invoking "liberalism" are very well taken. Your critique of structural violence is particularly thought-provoking for archaeologists -- who are interested in similar processes in the past and sometimes too easily fall on the crutch of structural explanation.

    1. Thanks, Matt, glad it was helpful! I should say re: the SL, you probably know a lot more about the on-the-ground realities than I do, but I am more interested in reading them largely through Farmer's eyes, as a potential ideal-type of the radical alternative to liberal humanitarianism, and also politically in the sense of being suspicious of liberal claims about moral imperatives.

      I would be interested in learning more about how structural violence is used in archaeology - shoot me an email, maybe?
      Thanks for reading!

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  2. Thanks for taking the time to write and reflect on this Sam. I really enjoyed reading the post.

    Reflecting on the idea that our actions and analysis are inherently positioned, as you have done, is critically important. Though there are certainly myriad frameworks that one could draw on to position supposed neutrality, I also find myself partial to a material analysis.

    Nevertheless, I'm not sure that recapitulating a Marxist analysis actually means that Marxists solutions are the way to go. While the world may be divided "sons of bitches" and those who aren't, I don't think that it necessarily follows that if you fight with the non-sons-of-bitches and non-sons-of-bitches suddenly gain power, that they won't become sons of bitches. In terms of PIH, certainly I would love to say that Jim Kim seems to have become an ardent proponent of capital b/c he always was a "son of a bitch," but alas, I think that that would be glossing over the actually complexities that are key to understanding what politics actually is.

    I'd love to see you continue to write about this, but to go beyond Farmer and think more about structure. Certainly structural violence is one concept that, as you so eloquently have pointed out, can be neutered. But how are we to understand "radical alternatives" to political action that get beyond juxtaposing armed resistance of the virtuous and liberal humanitarianism?

    I would also point out that given the emphasis on individual virtue that seems to be a strong theme, I would like to see you rethink how you talk about ethics. You seem to, on the one hand, juxtapose the ethical and the political, yet on the other hand, point to an underlying ethics of virtue (or maybe something more akin to a Freire conscientization, which I would still consider a strong ethical framework), as essential to a radical political project.

    1. Hi Nicole,
      Thanks for reading and for a very thoughtful reply! I sympathize with your critique of Marxist solutions – probably Scott’s ‘Seeing like a State’ is a good historical overview of what happens when non-SOBs take power. Am I wrong to take your call to think about structure to be an anarchistic one? At the very least, it is a (perhaps THE) question of the Left today. I haven’t been involved in, but have tried to follow, some of the debate on the Occupy movement. I think those with experience there would be better placed to offer insights.

      RE: ethical/political, let me be clear, I don’t see them as dichotomous (and thus not juxtaposable), but as fundamentally interwoven. Indeed, I attempting to diagnose (in a popular form of global health) the liberal tendency which divides them, and through which the ethical comes to hide or disguise the political (here, purely from Schmitt, but reflected in Trotsky and others). My own reading of ethics is largely in the Foucaultian sense of a practical free work on the self, which I find largely absent from at least Marx himself, where the domain of the ethical is dismissed largely as ideology and thus not worthy of constructive engagement except to denounce. In this sense, I am concerned with the individual and of course with the individual’s engagement in relation to a set of moral-political codes.

      Thanks again for reading and engaging! I’m glad it sparked something in you!
      Best, Sam

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  3. **apparently this will have to be in 2 posts because of length...

    First, I feel very fortunate to have had the chance to have read this and to put it in my files. Thank you Sam.

    Second, in reference to footnote 14 (re surplus value), see John Lanchester's excellent recent essay "Marx at 193" in last month's LRB for an excellent, readable summary of surplus value.

    As for your post, it deserves a lot more attention than I probably can give it right now, but here are some quick reactions:

    First, I think the phenomenon on professionalism is the most important aspect of your post; but it's a bit latent, and cries out for some emphasis. For me, the keep passage in the whole post is:

    "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."

    Everything in your post seems to turn on this - the political/ethical dichotomy, the figure of Dr. Paul Farmer vs. Dr. Norman Bethune, and indeed the professional(izing) scene of the introduction (and the grounds upon which you are writing this up).

    That said, when you think about PIH and humanitarian aid as industrial or professional (or at least when you put this in the foreground) I think that some things change - for instance, things you label naive can be understood as inert or institutional or even cynical, which (more likely, in this context) they are - that is, part of some professional apparatus that is very much aware (off the record) of the naivete of its own professional line, contradictions and limitations - one that knows that it has made its fair share of Faustian deals, and that has come to terms with that. I think this is important, because (in my experience with these kinds of institutions) its how they work - a kind of trained lack of attention to certain complex political realities, cause and effects, and a quiet hope that the ends justify the means. If there is any big critique I have of your post it is in those moments when you use the label 'naive' (perhaps naively yourself, to be honest) - while I am very confident that a lot of interns, grad students and first or second year in the field aid folk live and breathe off their own kool aid, I think this kind of abates after a while and most slip into the kind of inertia that most of us suffer from in our own everyday and professional lives... Does that make sense?

  4. But bringing professionalism to the foreground also allows you to emphasize some time and space elements that your post is begging for... And here I'm talking about scale. The reason that places like PIH are more ethical/industrial and less political/historical, is because these folks are contracted globetrotters - and it makes it very hard to be political when you operate in those terms. Again, this is me suggesting a more pragmatic approach - the non-institutional, non PIH farmer at his Haitian hospital is a very different farmer than the HMS/PIH Farmer of years later... with different capacities and capabilities.

    Lastly, you should consider the professionalized/humanistic/ethical dimensions of revolutionary practice too. As I'm pretty sure things are just as jaded and dire on the other side, sadly...

    There is a third way here that is more cynical, less political, less ethical, yet equally ideological - the way of absurdism, the road towards politico-ethical disavowal. Its the road taken by the angry, cynical, complicit, Northern Irish medical missionary who sits at his district mission hospital and treats soldiers and civilians alike and hates them both equally, and drinks his whisky at night cursing God because of the problem of theodicy, and only goes on because he knows of no other way - its a different kind of inertia, but one that is equally human. Its the kind of practice Camus would appreciate.

    It's kind of the way I find myself appreciating football these days, to be honest (with all the capitalism and salaries and corporate greed and petro dollars - it's horrible, and I'm part of it, but when Song tracks back and expertly cuts off a passing lane and forces a turnover, and then sends a through ball to RVP or Theo Walcott, who slots it home, it does make me feel more 'human', even if the conditions around the 'Emirates' are covered with politico-ethical crap. And I suppose, one could defend/appreciate performing a successful cleft-lip and palette surgery in a Peruvian scene on the same grounds...

    Anyhow, let me thank you for this post. It's very good.

    1. Hey Jason,
      Thanks for such a thoughtful, supportive, and careful reply! I’m so pleased that you took the time to engage with me in such detail.

      I’ll check out Lanchester’s article. It’s nice to know there’s a public voice in the UK (alongside probably Eagleton – I’ve seen his ‘Why Marx was Right’ around here and there, want to read it soon) articulating this outside the academy.

      I think the professional angle is very important, and gets around to the other type of domination I see so often in medicine – the Kantian/Foucaultian knowledge, expertise, etc . related to enlightenment. For me, this speaks to a different kind of parrhesia that I’m not sure how to handle myself (lest I be injured in speaking!), or how to ask other doctors or doctors-to-be to handle, except to grapple with it. But also, I think it goes beyond professionalism. If, putting aside PIH for the moment, we think about Quaker missionaries (cf. Ilana Feldman’s ‘The Quaker Way’) or other ostensibly non-professionalized (albeit still mobile) sovereignties, the common thread that I see more prominently is the humanist one with all of its problems. But as you say, the jadedness and surely the professional element exist also in revolutionary movements/armed forces (cf. Che’s diary in the Congo, where one could put the failure down to – outside of paternalism, racism, ahistoricity, lack of cultural training, etc. – a question of the Cuban troops being unable to ‘professionalize’ revolutionaries – and probably not just Congolese but also themselves).

      I like too the nuanced use of ‘inert’ rather than ‘naïve’; your experience in these types of orgs is vital to correcting what has largely been my paralytic fear of engaging at all outside of critical research. I do sense from other conversations I have had about these inconsistencies that people do – as you say – recognize them, but tend to repress them (usually unsuccessfully). Part of my use was intentionally rhetorical for those readers who haven’t thought about this issue very much, perhaps to give movement to that inertia! I am particularly interested, in current/future work, in exploring the ways in which this inertia is also tied to ‘human’ dreams in their bourgeois forms – the desire to build nuclear families, to buy a home, etc. – that come to excuse or support the inertness of that inertia. In this sense, too, one could see these as elements of professionalization (which they are), but perhaps also outside of the professional domain as general longings of/under bourgeois life? I am still thinking through a lot of this, but see if you’re interested my other post on love/humanism re: the question of the ‘family’ vs. ‘humanity’ – or, who is Che’s family?

      I like the distinction of young/older Farmer, but perhaps not as a question of scale/institutionalization. For me, the real juncture at that point would not have been ‘how to scale up?’ but ‘how to link to radical politics?’ Of course, I understand the Faustian bargain made under the logic of a leftist Catholic humanism, but I’m interested in what the anti-humanist choice would be, and how it would become possible to construct it.


    2. (continued from 1st part of entry)

      RE: revolutionary ethics – this may very well become a major focus of my future work. If, following Nikolas Rose and others, the plane on which our politics will be fought for the near future is the ethical, then I refuse to think that it’s sufficient for the radical response to be mere denunciation of the ethical as bourgeois ideology (which, I think, has largely been the response thus far, with some exceptions – particularly works by the likes of Merleau-Ponty and Trotsky around the time of Soviet terror). It is surely of some genealogical interest that radical theory has rarely attended to the Foucaultian ethical self, and in addition to trying to understand why this seems to be the case, I am (partially through this blog, partially through my research, and wholly in my day-to-day thought) seeking to contribute to the project of seriously engaging the revolutionary ethical self (the concept of which I don’t see as necessarily and therefore irretrievably bound in the ideological capitalist fiction of the monad).

      The cynical missionary idea is interesting, but I still see even the absurdity of the practice as a politics and ethics in itself, no? I lost interest in Camus after reading ‘The Rebel’ and his argument that rebellion was nihilistically against the human condition – written at a time when anticolonial struggles were taking place against very real forms of domination, not essences of the ‘human condition’. Apparently, Camus gave a talk that Fanon attended (in shock) in which Camus argued against aiding Algerian families during the liberation war (a type of ‘humanitarianism' that I think would in some ways mirror Bethune’s approach).

      The football analogy is perfect – I sorely miss the ‘English Premier League’ these days. Care to start an ‘FC United’ version of Arsenal? It’s true that there are some of the same elements there – presumably there are numerous pleasures associated with PIH work (cf. Ian’s 2011 article on race, illness, and pleasure in Barbados). It is precisely this type of complicity that I’m interested in, especially in revolutionary movements – the pictures of Che and Fidel playing golf together come to mind. But, to end on a somewhat brighter note from the Birmingham School/Hall – one could open up these practices to different types of readings, to ways in which practices that seem strictly in the domain of the hegemonic could be subverted for different and more radical uses. This is why I, perhaps to avoid the parrhesia but perhaps because there is already truth to it, stick to the idea that in the terrain of ideology, there are spots dominated by hegemony, others by counterhegemony; some that are contested, and some that lie uncontested. How to classify practices in these ways, seems to me, mostly a mystery of a Marxist ethics of the future (in which practices are judged as revolutionary/counterrevolutionary not on intentions but on historical outcomes).

      In any case, many thanks for your support and engagement!

    3. Seems like you are leaning towards "works by the likes of Merleau-Ponty and Trotsky around the time of Soviet terror" as a way to be radical without disavowing the ethical as a tactic, right? Does Graeber fill in that space for you? (I ask this not knowing anything really about his anarchism.)


I guess I am getting old. Camus now seems like the only approach that makes any sense. Everything else feels either futile, like selling-out, or is suicide-inducing. Sigh...

    4. Yes, those works and Graeber's (the couple I have read have been his more anthropological rather than his activist work, which is on my long reading list). I find that genealogically speaking, Marxist work around the time of Stalin was forced to take on the ethical domain because of the kinds of terrors being propagated in the name of Communism - it is more a question that the historical moment led Marxists to think about the ways in which Marxist humanism could be or could not be compatible with terror. And too, I think some good theoretical work on anti-humanism came out of this period (whereas after the Holocaust, anti-humanism was largely seen as being associated with the dark side of reason and Nazi horrors - thinking of the critique of Nietzsche and Adorno/Horkheimer's 'Dialectic of Enlightenment').

      Have you read Wilde's 'The Soul of Man under Socialism'? It might be a bit more hopeful! :)

  5. This is a very insightful essay/post and - as someone currently teaching both Farmer and Fassin in my Medical Anthropology and Global Health courses - I find it very helpful. I recently had my students read a wonderful chapter by Fassin where he distinguishes between the "ethics of life" and the "ethics of justice" in re. the causes of (and responses to) the AIDS epidemic in South Africa. The difference between these two ethical positions seems to characterize not only humanitarian efforts v. social/political movements, but also helps me understand my students' difficulty/resistance with understanding the need to address the social determinants of health in more radically-sustainable ways (Fassin cites the S. African government's cash payments to poor people with AIDS vs. investment in expensive ARV drugs...) - a resistance that reflects how deeply-rooted cultural values of (neo)liberalism really are. Thanks for this post and for your great blog!

    1. Dear Kristin, thanks for writing and I'm glad you found it useful! Probably you have read Jim Ferguson's article 'The Uses of Neoliberalism', which is another way of thinking about neoliberal arts of government and the flexibility therein. I do find Fassin's work important, particularly his call for a moral anthropology, but I sometimes sense that he doesn't dig hard enough in his archaeology. I am thinking especially of the intro or preface of his recent English book on humanitarian reason, in which he claims to be doing a kind of genealogy aimed at problematizing humanitarianism, but only interrogates certain concepts/words while leaving others (e.g. benevolence, altruism, suffering) unexplored. These too are to some extent recent ways of constructing the moral/social world, not ahistorical givens, and I think we have to turn to other scholars to help us go deeper (one good example is Thomas Dixon's 'The Invention of Altruism').

      In any case, thanks for reading and am glad you enjoyed it!
      Best, Sam

  6. I am an anthropologist, born in Peru, who spent 25 years working for indigenous peoples in the Amazon, in which context I participated in the foundation of several indigenous peoples' local, regional, national, and international level organizations, today key players at multiple political levels world-wide. I can tell you Sendero Luminoso forced and killed numerous indigenous peoples once their small children were forced to to go away with them and the concept of state advocated came to call for total submission. I too came to be considered an enemy and had my life threatened twice after refusing to form part of the organization, due to their concept and policy of state formation, as well as lack of understanding of regional realities (almost all came from the highlands, where pressure upon the Amazon has typically been quite destructive to its peoples and environment). SL had seen my work and wanted me on their team, but how could I if they were looking to impose those very top down approaches I originally went to study when carried out by missionaries? The peoples I worked closely with were struggling over their lands, territories, intercultural health and education. SL did not support these and considered those who did an enemy.
    That said, and again looking out on the world from the optics of both indigenous peoples and marxist anthropology, I wonder about how priorities to intervene medically are set in general. There are entire groups on the verge of disappearing due to epidemics, a long list of vector borne infections and, even, lack of resistance to "Western" viruses, as among indigenous peoples in voluntary isolation. Such peoples are being raped at present by oil companies, timber interests, dam construction, and such. The organizations representing these populations are deeply engaged in the struggle to transform the political economic conditions accounting for their current state. I have no words to express here the barbarities undergone. I just can't see any medical team willing to respond and act in a serious, committed and politically economic relevant way.
    It leads me to ask whether not acting is not also a way of supporting the current state of affairs, in an apparently small, insignificant and inconsequential group of indigenous peoples for those currently engages in yet another wave of primitive accumulation at whatever price, those of numerous human lives included.
    I am currently a research fellow at the department Paul Farmer leads and quite grateful and respectful of him and his enterprise. I believe certain things cannot always be judged properly from the outside, based on theory alone.

    1. Dear Lissie,
      Thanks for reading and sharing your thoughts. I respectfully acknowledge your experience of the SL. As I said in the essay, I'm neither interested in defending/critiquing the SL, nor a grounded exploration of the ways in which it grew distant from the people it claimed to support. This is an important project for others, but I've been more interested in a different type of anthropological exploration of 'studying-up' - seeing the way in which Farmer read the SL as a ideal-typical revolutionary group (ideologically, if not really, based on Farmer's brief discussion in 'Infections and Inequalities') that offered him a mirror by which to self-reflect.

      I sympathize with the idea that it is difficult to see a medical team responding in a way that is relevant to political economy, particularly among indigenous groups. I agree that 'not acting' (which is of course a form of action) can in some cases support the current state of affairs (though historical and anthropological assessment of the humanitarian impulse to act leads one to a strong rebuttal). I ask for a different type of acting.

      Like you, an anthropologist informed by marxist work, I too agree certain things can't be judged from the outside on theory alone. This is of course the concept of praxis, or Mao's quite anthropological exhortation to 'oppose book worship', which I'm sure you've read and enjoyed (

      Thanks again for reading and responding.
      Best, Sam

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  8. Hi Sam,
    I loved reading this piece! Well written!

    Merlen Hogg

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  31. All social medicine recognizes that social inequity penetrates the body and causes sickness and death. Farmer understood this. The doctors at the Social Medicine program at Montefiore Hospital in the Bronx, where childhood asthma is the worst in the world and mainly affects the black and Hispanic population, understand this. The PIH clinic in Peru was bombed by Sendero Luminoso because their entire dynamic involves heightening the desperation of the people to turn them into Maoists that support their Sendero cause. Farmer's approach was quite simply to refuse the blather offered by the billionaire class that it's not materially possible to offer reasonable living conditions and healthcare to everyone. He rejected that and rightly so. The Capitalist system, as Charlie Chaplin knew, chews up people and spits them out. The poor are not "important" and therefore unworthy of "investment". There is no doubt that philanthropists like the Gates are fraught with contradictions and aim to make themselves the undemocratically chosen leaders of the world, deciding where the money goes, who is worth investing in, and so on. These people were and are necessary to any humanitarian work. From where shall the funds come? What do you suggest? Certainly, Sendero Luminoso's interest is in making the people as desperate as possible, as it has proven over and over again. Dr. Farmer was not responsible for all these contradictions. He made himself responsible only for curing as many people as possible with the philosophy of accompaniment. That's a lot of pressure and it probably killed him young. The "political enemy" cannot be fought when you are dying and sick. The true problem is seeing the world as friends and enemies and the diminishment of kindness in the greater population. There is no political solution without a social and cultural solution. The "revolutionary" Sendero Luminoso "cares for" the people by turning them into narcotraficantes -- and taxing them for the coca production. Some revolution!

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