Mountains Beyond Mountains Study Guide
Mountains Beyond Mountains book cover

STUDY NOTE

Globalization and Paul Farmer’s Reframing of Care

By Professor Matthew Sparke, Geography and International Studies, University of Washington
Email: sparke@u.washington.edu
Homepage: http://faculty.washington.edu/sparke/

[I]t is in the context of global forces that the suffering of individuals acquires its own appropriate context. – Paul Farmer

What You Can Learn from This Topic

  • How does reading Kidder’s account of Paul Farmer’s work make us reflect on health inequalities in different parts of the world and our relationship to them?
  • How does understanding globalization aid our understanding of these inequalities?
  • What is structural violence?
  • How does Paul Farmer’s work help to reframe the concept of care in a global context?
  • What areas of research and study help further clarify these concepts?

Reading Note: Terms such as globalization that are shown in these notes in bold have longer definitions provided in UW’s online Mountains Beyond Mountains glossary.

Caring about the Context of Care

Reading about Paul Farmer’s work in Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World (Kidder, 2003), tends to make both university students and professors alike reflect on their privilege. At the same time, it urges us to use our privilege to end the suffering of others who are systematically underprivileged. It is a book that is clearly meant to make us care about places and people beyond the university. But, more than this, it is also a book that invites us to re-think care itself as an engaged and expansive kind of responsibility to the world. In making us think like this, Mountains Beyond Mountains often takes us outside our comfort zones. Certainly this was its effect on me as a professor who teaches and writes about globalization. Rather than see this discomfort as a problem, though, I want to suggest in what follows that the uncomfortable feelings and thoughts provoked by the book can also create important opportunities for learning, including learning about the relationships between ill-health in a places such as Haiti and the many global ties comprising globalization.

The example of global responsibility set by Farmer himself represents a remarkable illustration of how to connect work in privileged settings (in his case, Harvard University and Boston’s Brigham and Women’s Hospital) with caring responses to social injustice in some of the most deprived parts of the planet. His are not knee-jerk responses to the needy, nor the simple subordination of academic work to direct action that some more romantic readers of Kidder’s book might initially imagine. Instead Farmer leverages many lessons, ideas, knowledges, skills and technologies developed in the modern research university in order to make his response to deprivation more effective.

A key part of being more effective as an advocate of the poor is Farmer’s ability to reframe their health problems in terms of systemic global problems. “We have to think of health in the broadest possible sense,” he says (Kidder, 2003: 91). This is why his mission – as he more recently explained to a reporter from Business Week – “is less about assisting the distant needy and more about repairing a broken world” (quoted in Arnst, 2006: 20). His attention to breakdowns in the world system becomes especially clear in Farmer’s own academic writing, writing which Mountains Beyond Mountains begins to introduce, but writing which, because it is so accessible and compelling in its own right, must definitely go on the must-read list of anyone who wants to go beyond the personal portrait of ‘Dokté Paul’ provided by Kidder’s book.

One reason Farmer’s written work is so useful is that it models the kind of rigorous global thinking that is necessary to make responses to a ‘broken world’ both ethically and politically responsible, which is to say responsive both to the people they are meant to help and to the contexts in which that help is offered. In this way, his approach clearly represents something different from both personal charity and traditional state-run development aid. Too often such charity and aid are aimed at the ‘needy’ by practitioners in ways that repeat older imperial ideas of ‘civilizing mission’ (in which westerners went around the world thinking that they were saving the natives even though they were killing them through colonization). Instead, by actually reminding us about the deadly legacies of colonialism and imperialism, and by persistently highlighting other more recent global processes that create local experiences of ill-health, Farmer’s approach involves what I will here call caring about the context of care.

Caring about the context of care following the example of Farmer means connecting the local with the global. One way of doing this is to draw on the work of scholars from the social sciences and humanities who have sought in recent years to make sense of globalization (for some useful introductions to globalization see Held et al, 1999; Sklair, 2002; and Steger, 2005). A central goal of these notes is to underline how one of the possibilities for learning opened-up by Farmer’s story involves rethinking the dominant common-sense about globalization creating a global ‘level-playing field’. Mapping the global ‘mountains’ beyond the local ‘mountains’ of ill-health in Haiti makes this common-sense conception of globalization seem a lot less sensible. The ‘mountains’ to which Farmer’s story draws our attention are far from being leveled. They include everything from Haiti’s huge foreign debts to its rocky relations with the U.S. and France. By acknowledging the uneven development represented by these global relations and by seeing how they make life in Haiti so hard, it is therefore possible to see what is wrong with arguments that globalization has ‘leveled’ the ‘playing field’ and made the world – in the characteristically curt but comfortable formulation of New York Times columnist Thomas Friedman – ‘flat’ (Friedman, 2005). I will come back to this useful kind of discomfort at the end. However, to begin with I need to describe another equally useful but more personal discomfort that I myself experienced in reading Mountains Beyond Mountains.

Mountains of Discomfort

As a professor of Geography and International Studies, I regularly teach a course at the University of Washington entitled Introduction to Globalization (GEOG 123/SIS 123 at http://faculty.washington.edu/sparke/global123.htm). A core concern of the course is the way globalization creates both new global interdependencies and new inequalities at the same time. Global interdependencies basically consist of linkages between the lives of people in different parts of the world. The linkages may be economic, political, social, cultural or even ecological, but what makes them interdependencies is that they create bonds of fate between people in different parts of the world. According to celebrants of global capitalism such as Friedman it is these bonds that have created a flat world, plunging everyone everywhere into a fateful struggle to be fittest at playing the profit-making games of the global level playing field. But a big problem with this flat world economic game plan is that the playing field is not level, and the interdependencies do not create a single common fate but rather highly uneven fates. One of my main concerns in my course is to underline that the new ties of globalization do not therefore create equal outcomes everywhere and instead often involve creating privilege in one place by creating underprivilege, exploitation and instability elsewhere (see also Sparke, 2004, 2005 and 2006). I am therefore very familiar with the themes of global interconnection and inequality that are introduced by Mountains Beyond Mountains. But before reading the book I had never attempted to examine the ties between global economic integration and global health. The example of Farmer’s work made me feel that this was a big mistake. As a discomforting spur to engagement, then, the book made me think about how I might improve my academic presentation of globalization by including attention to global health problems in the lecture hall. At the same time the book also took me out of my academic comfort zone altogether by obliging me to think again about the need to connect those lecture-hall discussions with more caring and careful contributions in the world beyond the university. To begin, let me explain here how Farmer’s own extraordinary care for context models a frame-breaking approach to action beyond the university.

Farmer’s Frame-Breaking Moves

Farmer himself obviously cares passionately for poor people and for both relieving and halting their suffering. He is extraordinarily energetic and self-sacrificing in his personal contribution of healthcare services in rural Haiti, inner-city Boston, the slums of Peru, the Russian prison system, and all the other places where he and Partners in Health have made interventions. Yet the fact that all these interventions are made collaboratively by working carefully with locals means that even these direct acts of care-work break the frame we often assume when we imagine an individualized and cubicle-ized doctor-patient relationship. In addition to the collaborative characteristics of his care-work, it needs noting too that Farmer breaks the frame of traditional thinking about medicine in a second and crucial way by highlighting the global contexts that create the local experiences of ill-health to which he and his colleagues respond. Even from just the stories Kidder provides, we can see that Farmer cares thus to connect the local with the global at the same time as he connects the personal with the political. Whether he is explaining how a US-built dam and development scheme created malnutrition in Haiti, or highlighting how the Latin American debt crisis contributed to the emergence of Multi Drug Resistant Tuberculosis in cities such as Lima, Farmer repeatedly seeks to say and show that if one truly cares for the sick one should also care about the political and economic developments that create the conditions for sickness in the first place (for a really useful discussion of how globalization demands that we also reframe our traditional concepts of justice see Fraser, 2005).

I think it is important to stress Farmer’s careful attention to local-global ties because some parts of Mountains Beyond Mountains might lead readers to think of his story as a purely personal drama involving an individual heroic doctor and his destitute patients. Reading Kidder’s commentary as a drama of this kind, it might be possible to form an impression of Farmer as a maverick medic invested in a messianic mission of saving everyone he personally touches. Even Kidder’s subtitle for the book – The Quest of Dr. Paul Farmer, A Man Who Would Cure the World – could possibly be interpreted this way, conjuring-up an image of a kind of George Clooney figure who has broken out of the set of ER, marched full-speed through the wealth of an American downtown, and headed-off on a jet to save the planet. But inspired by liberation theology as he might be, and focused on being “an action kind of guy” (Kidder, 2003: 79) as he assuredly is, Farmer is not a messianic maverick. He is clearly aware that the forces causing ill-health globally are much too big and too structural for any individual to be able to change them all alone. And rather than use this kind of observation as an excuse for inaction, Farmer shows that by better understanding these big structural forces we can actually make more informed, collaborative and useful interventions on the ground. In other words, he repeatedly breaks the frame of the traditional medical drama with its lone sick patient and lone heroic doctor, and by doing so works himself to dispel the messianic (and racially-coded) idea that an individual white man in a white coat can save the world. Indeed, as anyone who has read one of Farmer’s books knows well, the personal doctor-patient stories are always placed in a larger account of broader local-global interdependencies.

Even the alliterations Farmer uses in the titles of his books poetically point to ties between local incidences of ill-health and the global organization of inequality and power. Pathologies of Power: Health, Human Rights, and the New War on the Poor (Farmer, 2005) directly connects the spread and deadly impact of health pathogens (biological agents that cause disease) with the economic and political forces that Farmer finds to be the most pathogenic in creating contexts of risk for the development of disease and the systemization of suffering. This is why he argues that “it is in the context of these global forces that the suffering of individuals acquires its own appropriate context” (2005: 41). Such contexts, Farmer shows, are not distributed randomly, but rather are steeply skewed by the “inegalitarian social structures” that produce what he so usefully labels “structural violence” (2005: 230-231). Likewise Infections and Inequalities: The Modern Plagues (Farmer, 1999) ties the ongoing scourge of infectious diseases such as tuberculosis, meningitis and malaria to the context of grinding poverty in the Global South, all the while underlining that the processes producing this poverty are intimately interlinked with economic life in richer parts of the world where the diseases have been largely controlled. And also adding attention to international economic structures and long distance political decisions to his epidemiological account, Farmer’s brilliant first book AIDS and Accusation: Haiti and the Geography of Blame (Farmer, 1992) links the emergence of AIDS in Haiti to transnational interconnections and uneven development. He shows that the resulting poverty of Haitians and the resulting turn by some to prostitution combined with visits from American tourists to bring HIV to Haiti (see al so Kidder, 2003: 199). By reframing the medical story this way and focusing on the transnational ties of money, moving people and microbes, Farmer is able to debunk the erroneous idea that Haiti was the original infection point from where HIV entered America.

As a geographer I cannot help noting how in rebutting the ‘geography of blame’ that depicted Haiti as a kind of island incubus of AIDS, Farmer adds a third frame-breaking line of argument to what therefore becomes a triangulating care for context. This might seem a rather too abstract way of putting it; so let me explain with a diagram of what I see as the three frame-breaking moves involved in Farmer’s efforts to map global mountains beyond local mountains (Figure 1 below). His first move – ‘collaboration’ (shown in red in Figure 1) – is to locate his efforts at patient care within a context of engagement with the local community, its practical struggles and its own understandings of the world. His second move – ‘transnationalization’ (shown in blue) – is to understand the individual accounts of ill-health in terms of a broader context of local-global interdependencies. “To explain suffering,” he argues thus, “one must embed individual biography in the larger matrix of history, culture and political-economy” (2005: 41). And his third move – ‘depathologization’ (shown in green) – is to criticize distorted accounts of disease that hide the history, culture and political economy of the transnational context through a form of geographical accusation that blames the victim: ‘that’s a bad place where all those bad things happen because of the bad and backward people there’. By depathologizing the local and showing how its problems are better explained by global interdependencies, Farmer also removes a classic culturalist excuse for double standards in health-care delivery and treatment: ‘those sorts of backward people and places do not deserve top quality health-care’. Instead, he argues that no one should be treated like an outcast. His take-home message for the Business Week reporter was therefore a simple one: health is a birthright for everybody no matter where they live (see Arnst, 2006).

 

Mapping Global Mountains Beyond Local Mountains

 Figure 1: Mapping Global Mountains Beyond Local Mountains

In Farmer’s work all three frame-breaking moves are closely interconnected. From his own books one can get an especially powerful sense of his commitments to examining global-local ties and debunking the pathologization of the local. But Kidder adds to this with his close-up accounts of collaboration at Zanmi Lasanate and the other clinics that Farmer and Partners In Health have helped establish. As a result, Mountains Beyond Mountains shows how the arrows of contextualization move back from the global to the local to Farmer’s personal care for patients. In other words, having broken the frame of the traditional medical focus on the body of the individual patient, and having thereby re-framed that body in terms of its relationships with both the local community and wider global interdependencies, Farmer goes back repeatedly to caring doctor-patient relationships, reinterpreting them and his work in light of his care for context. The resulting movement back and forth is clearly transformative; or, as Kidder suggests in an evocative description of Farmer’s commuting between Cange and Boston: “The trip was unsettling in either direction” (Kidder, 2003: 261).

As well as documenting his global movements, there are also clearly many lessons about Farmer’s approach to local collaboration that can be garnered from reading Mountains Beyond Mountains. One of the constants in this respect seems to be his ethnographic care for the knowledge produced by Haiti’s poor communities: knowledge of, amongst other things, the close relationships between poverty, hunger and illness. I will not address further here the practical collaborations that come out of this frame-breaking care by Farmer to working with (rather than ‘on’) local communities. Other UW faculty have written teaching notes addressing this, along with the ways in which such work relates to other projects of primary health-care in other places, including poorer parts of Seattle (e.g. Huntington Study Note). However, I do want to emphasize here that Farmer’s own ethnographic care for the voices of the poor means that his account of the global structures creating structural violence remains tied to intimately local accounts of the resulting suffering. “She’s crying ‘It hurts, I’m hungry.’” Kidder reports him as saying about a thirteen year old patient at Zanmi Lasante. “Can you believe it? Only in Haiti would a child cry out that she’s hungry during a spinal tap” (Kidder, 2003: 32). Such moments in Mountains Beyond Mountains connect directly to Farmer’s more extensive arguments about taking the voices of the poor seriously. “Structural violence,” he notes in Pathologies of Power, “generates bitter recrimination, whether it is heard or not. And given that residents of the barrio and the cities and neighborhoods like it are those that endure most of the world’s misery, they are precisely those most likely to have a vocabulary to explain a degree of pain, its position or nature” (Farmer, 2005: 25). Farmer’s approach seems effective because it is especially attuned to this vocabulary of pain. Rather than just thinking in terms of ‘cross-cultural’ communication, he breaks the frame associated with narrow and apolitical medical debates over ‘cultural competence’ and thereby combines communication with collaboration by treating communities who suffer as agents of knowledge production (for a fascinating discussion of the limits of ‘cultural competence’ talk by a UW anthropologist see Taylor, 2003 – students should note that Professor Taylor is teaching a related course in the Fall of 2006, HUM 201).

It is also because Farmer pays such close attention to the vocabularies of those who suffer that his other two other frame-breaking approaches – the transnationalization of diagnosis and the depathologization of treatment - are so effective. Unlike some of the dry academic discussion of globalization, Farmer’s work remains relentlessly concerned with the voices and struggles of the poor.

Resources for Further Study

For those who wish to explore these topics further, I now want to point to some of the literatures on global political-economy, neoliberalism and postcolonial theory that are useful to understanding the context of Farmer's work. While these literatures often seem vast and daunting, it helps to see the great multiplicity of names and writings as an asset rather than an obstacle to learning. As Farmer suggests himself: “Physicians, when fortunate, can alleviate the suffering of the sick. But explaining its distribution requires many minds and resources” (Farmer, 2005: 41). Follwoing this observation, but trying to provide as much coherency as possible, I have prepared two essays reviewing literatures that help us come to terms with the distribution of suffering in a global context.

My first literature review, How Research on Globalization Explains Structural Violence, highlights some of the ways in which research and writing on the interdependencies of contemporary globalization helps us understand what Farmer means by ‘structural violence.’ My second literature review, What Postcolonial Theory Tells Us about Haitian History and Struggle examines how Farmer's concern to depathologize the local as a locus of blame can in turn be understood and amplified through recourse to what are commonly called ‘postcolonial critiques’ of the legacies of historic globalization. For access to either of these essays, just click on their titles here. Let me close by noting that if you are in a rush and just need some of the globalization jargon decoded, go to the Meanings Beyond Mountains glossary (click on title).

References

Arnst, C. (2006, May 29). Health as a birthright. Business Week, 20.

Farmer, P. (1992). AIDS and accusation: Haiti and the geography of blame. Berkeley: University of California Press.

Farmer, P. (1999). Infections and inequalities: The modern plagues. Berkeley: University of California Press.

Farmer, P. (2004, May/June). Haiti’s wretched of the earth. Tikkun. Retrieved from http://www.tikkun.org/magazine/index.cfm/action/tikkun/issue/tik0405/article/040521.html.

Farmer, P. (2004, April 15). Who removed Aristide? London Review of Books, 26:8. Retrieved from http://www.lrb.co.uk/v26/n08/farm01_.html.

Farmer, P. (2005). Pathologies of power: Health, human rights, and the new war on the poor. Berkeley: University of California Press.

Farmer, P. (2006). The uses of Haiti . Monroe, Me.: Common Courage Press.

Held, D., McGrew, A., Goldblatt, D., & Perraton, J. (1999). Global transformations: politics, economics and culture. Stanford: Stanford University Press.

Kidder, T. (2003). Mountains beyond mountains: The quest of Dr. Paul Farmer, a man who would cure the world. New York: Random House.

Kim, J., ed. (2000). Dying for growth: Global inequality and the health of the poor. Monroe, Me.: Common Courage Press.

Sklair, L. (2002). Globalization: Capitalism and its alternatives. Oxford: Oxford University Press.

Sparke, M. (2006a). Political geographies of globalization: (2) Governance. Progress in Human Geography, 30:2, 1-16.

Sparke, M. (2006b). A neoliberal nexus: Citizenship, security and the future of the border. Political Geography, 25, 151-180.

Sparke, M. (2005). In the space of theory: Postfoundational geographies of the nation-state. Minneapolis: University of Minnesota Press.

Sparke, M., et al., (2005). The world social forum and the lessons for economic geography. Economic Geography, 81:4, 359-380.

Sparke, M. (2004). Political geographies of globalization: (1) Dominance. Progress in Human Geography, 28:6, 777–794.

Steger, M. (2005). Globalism: market ideology meets terrorism. Lanham, MD: Rowman & Littlefield.

Taylor, J.S. (2003). The story catches you and you fall down: Tragedy, ethnography, and “cultural competence.” Medical Anthropology Quarterly , 17:2, 159-181.

Suggested Courses

SIS 123 Introduction to Globalization (5) I& S Sparke Provides an introduction to the debates over globalization. Focuses on the growth and intensification of global ties. Addresses the resulting inequalities and tensions, as well as the new opportunities for cultural and political exchange. Topics include the impacts on government, finance, labor, culture, the environment, health, and activism. Offered jointly with GEOG 123.

SIS 333 Gender and Globalization: Theory and Process (5) I&S Ramamurthy Theoretical, historical, and empirical analysis of how current processes of globalization are transforming the actual conditions of women's lives, labor, gender ideologies, and politics in complex and contradictory ways. Topics include feminist exploration of colonialism, capitalism, economic restructuring policies, resistance in consumer and environmental movements. Offered jointly with WOMEN 333.

To learn more about the UW Common Book program, visit the Common Book website at: http://www.uwcommonbook.org