Pathologies of Power: Health, Human Rights, and the New War on the Poor (California Series in Public Anthropology)

Pathologies of Power: Health, Human Rights, and the New War on the Poor (California Series in Public Anthropology)

by Paul Farmer

ISBN: 9780520243262

Publisher University of California Press

Published in History/Africa, Reference

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Sample Chapter

On Suffering and Structural Violence

Social and Economic Rights in the Global Era

Growth of GNP or of industrial incomes can, of course, be very important as means to expanding the freedoms enjoyed by the members of the society. But freedoms depend also on other determinants, such as social and economic arrangements (for example, facilities for education and health care) as well as political and civil rights (for example, the liberty to participate in public discussion and scrutiny). Amartya Sen, Development as Freedom

Where do people earn the Per Capita Income? More than one poor starving soul would like to know. In our countries, numbers live better than people. How many people prosper in times of prosperity? How many people find their lives developed by development? Eduardo Galeano, "Those Little Numbers and People"

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

So suffering is a fact. Now a number of corollary questions come to the fore. Whenever we talk about medicine or policy, a "hierarchy of suffering" begins to take shape, for it is impossible to relieve every case at once. Can we identify the worst assaults? Those most at risk of great suffering? Among persons whose suffering is not fatal, is it possible to identify those most at risk of sustaining permanent and disabling damage? Are certain "event" assaults, such as torture or rape, more likely to lead to later sequelae than is sustained and insidious suffering, such as the pain born of deep poverty or racism? Are certain forms of insidious discrimination demonstrably more noxious than others?

Anthropologists and others who take these as research questions study both individual experience and the larger social matrix in which it is embedded in order to see how various social processes and events come to be translated into personal distress and disease. By what mechanisms, precisely, do social forces ranging from poverty to racism become embodied as individual experience? This has been the focus of most of my own research in Haiti, where political and economic forces have structured risk for AIDS, tuberculosis, and, indeed, most other infectious and parasitic diseases. Social forces at work there have also structured risk for most forms of extreme suffering, from hunger to torture and rape.

Working in contemporary Haiti, where in recent decades political violence has been added to the worst poverty in the hemisphere, one learns a great deal about suffering. In fact, the country has long constituted a sort of living laboratory for the study of affliction, no matter how it is defined. "Life for the Haitian peasant of today," observed the anthropologist Jean Weise some thirty years ago, "is abject misery and a rank familiarity with death." The biggest problem, of course, is unimaginable poverty, as a long succession of dictatorial governments has been more engaged in pillaging than in protecting the rights of workers, even on paper. As Eduardo Galeano noted in 1973, at the height of the Duvalier dictatorship, "The wages Haiti requires by law belong in the department of science fiction: actual wages on coffee plantations vary from $.07 to $.15 a day."

In some senses, the situation has worsened since. When in 1991 international health and population experts devised a "human suffering index" by examining several measures of human welfare ranging from life expectancy to political freedom, 27 of 141 countries were characterized by "extreme human suffering." Only one of them, Haiti, was located in the Western hemisphere. In only three countries on earth was suffering judged to be more extreme than that endured in Haiti; each of these three countries was in the midst of an internationally recognized civil war.

Suffering is certainly a recurrent and expected condition in Haiti's Central Plateau, where everyday life has felt, often enough, like war. "You get up in the morning," observed one young widow with four children, "and it's the fight for food and wood and water." If initially struck by the austere beauty of the region's steep mountains and clement weather, long-term visitors come to see the Central Plateau in much the same manner as its inhabitants do: a chalky and arid land hostile to the best efforts of the peasant farmers who live here. Landlessness is widespread and so, consequently, is hunger. All the standard measures reveal how tenuous is the peasantry's hold on survival. Life expectancy at birth is less than fifty years, in large part because as many as two of every ten infants die before their first birthday. Tuberculosis and AIDS are the leading causes of death among adults; among children, diarrheal disease, measles, and tetanus ravage the undernourished.

But the experience of suffering, it's often noted, is not effectively conveyed by statistics or graphs. In fact, the suffering of the world's poor intrudes only rarely into the consciousness of the affluent, even when our affluence may be shown to have direct relation to their suffering. This is true even when spectacular human rights violations are at issue, and it is even more true when the topic at hand is the everyday violation of social and economic rights. Because the "texture" of dire affliction is better felt in the gritty details of biography, I introduce the stories of Aciphie Joseph and Chouchou Louis. Since any example begs the question of its relevance, I will argue at the outset that the stories of Aciphie and Chouchou are anything but "anecdotal." In the eyes of the epidemiologist as well as the political analyst, they suffered and died in exemplary fashion. Millions of people living in similar circumstances can expect to meet similar fates. What these victims, past and present, share are not personal or psychological attributes. They do not share culture or language or a certain race. What they share, rather, is the experience of occupying the bottom rung of the social ladder in inegalitarian societies.

Aciphie's Story

For the wound of the daughter of my people is my heart wounded, I mourn, and dismay has taken hold of me. Is there no balm in Gilead? Is there no physician there? Why then has the health of the daughter of my people not been restored? O that my head were waters, and my eyes a fountain of tears, that I might weep day and night for the slain of the daughter of my people! Jeremiah 8:22-9:1

Kay, a community of fewer than three thousand people, stretches along an unpaved road that cuts north and east into Haiti's Central Plateau. Striking out from Port-au-Prince, the capital, it can take several hours to reach Kay, especially if one travels during the rainy season, when the chief thoroughfare through central Haiti turns into a muddy, snaking path. But even in the dry season, the journey gives one an impression of isolation, insularity. The impression is misleading, as the village owes its existence to a project conceived in the Haitian capital and drafted in Washington, D.C.: Kay is a settlement of refugees, substantially composed of peasant farmers displaced more than forty years ago by the construction of Haiti's largest dam.

Before 1956, the village of Kay was situated in a fertile valley, and through it ran the Rivihre Artibonite, Haiti's largest river. For generations, thousands of families had farmed the broad and gently sloping banks of the river, selling rice, bananas, millet, corn, and sugarcane in regional markets. Harvests were, by all reports, bountiful; life there is now recalled as idyllic. When the valley was flooded, the majority of the local population was forced up into the stony hills on either side of the new reservoir. By all the standard measures, the "water refugees" became exceedingly poor; the older people often blame their poverty on the massive buttress dam a few miles away, bitterly noting that it brought them neither electricity nor water.

In 1983, when I began working in the Central Plateau, AIDS was already afflicting an ever-increasing number of city dwellers but was unknown in areas as rural as Kay. Aciphie Joseph was one of the first villagers to die of the new syndrome. But her illness, which ended in 1991, was merely the latest in a string of tragedies that she and her parents readily linked together in a long lamentation, by now familiar to those who tend the region's sick.

The litany begins, usually, down in the valley, now hidden under the still surface of the lake. Both Aciphie's parents came from families who had made a decent living by farming fertile tracts of land-their "ancestors' gardens"-and selling much of their produce. Her father tilled the soil, and his wife, a tall and wearily elegant woman not nearly as old as she looks, was a "Madame Sarah," a market woman. "If it weren't for the dam," he once assured me, "we'd be just fine now. Aciphie, too." The Josephs' home was drowned, along with most of their belongings, their crops, and the graves of their ancestors.

Refugees from the rising water, the Josephs built a miserable lean-to on a knoll of high land jutting into the new reservoir. They remained poised on their knoll for some years; Aciphie and her twin brother were born there. I asked what had induced them to move higher up the hill, to build a house on the hard stone embankment of a dusty road. "Our hut was too near the water," replied their father. "I was afraid one of the children would fall into the lake and drown. Their mother had to be away selling; I was trying to make a garden in this terrible soil. There was no one to keep an eye on them."

Aciphie attended primary school in a banana-thatched and open shelter in which children and young adults received the rudiments of literacy in Kay. "She was the nicest of the Joseph sisters," recalled one of her classmates. "And she was as pretty as she was nice." Aciphie's beauty-she was tall and fine-featured, with enormous dark eyes-and her vulnerability may have sealed her fate as early as 1984. Though still in primary school then, she was already nineteen years old; it was time for her to help generate income for her family, which was sinking deeper and deeper into poverty. Aciphie began to help her mother by carrying produce to a local market on Friday mornings. On foot or with a donkey, it takes over an hour and a half to reach the market, and the road leads right through Piligre, site of the dam and a military barracks. The soldiers liked to watch the parade of women on Friday mornings. Sometimes they taxed them, literally, with haphazardly imposed fines; sometimes they levied a toll of flirtatious banter.

Such flirtation is seldom rejected, at least openly. In rural Haiti, entrenched poverty made the soldiers-the region's only salaried men-ever so much more attractive. Hunger was a near-daily occurrence for the Joseph family; the times were as bad as those right after the flooding of the valley. And so when Aciphie's good looks caught the eye of Captain Jacques Honorat, a native of Belladhre formerly stationed in Port-au-Prince, she returned his gaze.

Aciphie knew, as did everyone in the area, that Honorat had a wife and children. He was known, in fact, to have more than one regular partner. But Aciphie was taken in by his persistence, and when he went to speak to her parents, a long-term liaison was, from the outset, a serious possibility:

What would you have me do? I could tell that the old people were uncomfortable, worried; but they didn't say no. They didn't tell me to stay away from him. I wish they had, but how could they have known? ... I knew it was a bad idea then, but I just didn't know why. I never dreamed he would give me a bad illness, never! I looked around and saw how poor we all were, how the old people were finished ... What would you have me do? It was a way out, that's how I saw it.

Aciphie and Honorat were sexual partners only briefly-for less than a month, according to Aciphie. Shortly thereafter, Honorat fell ill with unexplained fevers and kept to the company of his wife in Piligre. As Aciphie was looking for a moun prensipal-a "main man"-she tried to forget about the soldier. Still, it was shocking to hear, a few months after they parted, that he was dead.

Aciphie was at a crucial juncture in her life. Returning to school was out of the question. After some casting about, she went to Mirebalais, the nearest town, and began a course in what she euphemistically termed a "cooking school." The school-really just an ambitious woman's courtyard-prepared poor girls like Aciphie for their inevitable turn as servants in the city. Indeed, becoming a maid was fast developing into one of the rare growth industries in Haiti, and, as much as Aciphie's proud mother hated to think of her daughter reduced to servitude, she could offer no viable alternative.

And so Aciphie, twenty-two years old, went off to Port-au-Prince, where she found a job as a housekeeper for a middle-class Haitian woman who worked for the U.S. embassy. Aciphie's looks and manners kept her out of the backyard, the traditional milieu of Haitian servants. She was designated as the maid who, in addition to cleaning, answered the door and the phone. Although Aciphie was not paid well-she received thirty dollars each month-she recalled the gnawing hunger in her home village and managed to save a bit of money for her parents and siblings.

Still looking for a moun prensipal, Aciphie began seeing Blanco Nerette, a young man with origins similar to her own: Blanco's parents were also "water refugees," and Aciphie had known him when they were both attending the parochial school in Kay. Blanco had done well for himself, by Kay standards: he chauffeured a small bus between the Central Plateau and the capital. In a setting in which the unemployment rate was greater than 60 percent, he could command considerable respect, and he turned his attentions to Aciphie. They planned to marry, she later recalled, and started pooling their resources.

Aciphie remained at the "embassy woman's" house for more than three years, staying until she discovered that she was pregnant. As soon as she told Blanco, she could see him becoming skittish. Nor was her employer pleased: it is considered unsightly to have a pregnant servant. And so Aciphie returned to Kay, where she had a difficult pregnancy. Blanco came to see her once or twice. They had a disagreement, and then she heard nothing more from him.


Excerpted from "Pathologies of Power: Health, Human Rights, and the New War on the Poor (California Series in Public Anthropology)" by Paul Farmer. Copyright © 2004 by Paul Farmer. Excerpted by permission. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher. Excerpts are provided solely for the personal use of visitors to this web site.
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