Copyright © 1999 by the American Public Health Association, Inc. Volume 89(10), October 1999, pp 1486-1496

Farmer, Paul MD, PhD

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The field of health and human rights has grown quickly, but its boundaries have yet to be traced. Fifty-one years after the Universal Declaration of Human Rights, consensus regarding the most promising directions for the future is lacking; however, outcome-oriented assessments lead us to question approaches that rely solely on recourse to formal legal and civil rights. Similarly unpromising are approaches that rely overmuch on appeals to governments: careful study reveals that state power has been responsible for most human rights violations and that most violations are embedded in "structural violence"-social and economic inequities that determine who will be at risk for assaults and who will be shielded.

This article advances an agenda for research and action grounded in the struggle for social and economic rights, an agenda suited to public health and medicine, whose central contributions to future progress in human rights will be linked to the equitable distribution of the fruits of scientific advancement. Such an approach is in keeping with the Universal Declaration but runs counter to several of the reigning ideologies of public health, including those favoring efficacy over equity.

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Medicine and the allied health sciences have long been peripherally involved in work on human rights. Fifty years ago, the door to greater involvement was opened by Article 25 of the Universal Declaration of Human Rights, which underlined social and economic rights: "Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing, and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control."1

But the intervening decades have seen little progress in the press for social and economic rights, even though we may point with some pride to gains in civil or legal rights. That these distinctions are crucial is made clear by a visit to a Russian prison. The Russian Federation has traditionally been the United States' only serious competitor in the race to be the country with the highest rates of incarceration. With its current political and economic disruption, Russia has pulled ahead: some 700 per 100,000 citizens are currently in jail or prison. (In much of the rest of Europe, that figure is about one fifth as high.2)

In the full-to-bursting pretrial detention centers in which hundreds of thousands of Russian detainees await due process, many fall ill with tuberculosis (TB). Convicted prisoners who are diagnosed with TB are sent to one of more than 50 "TB colonies." Imagine a Siberian prison in which the cells are as cramped as cattle cars, the fetid air thick with tubercle bacilli. Imagine a cell in which most of the prisoners are coughing and all are said to have active TB. Let the mean age of the inmates be less than 30 years. Finally, imagine that many of these young men are receiving ineffective therapy for their disease-given drug toxicity, worse than receiving placebo-even though they are the beneficiaries of directly observed therapy with first-line antituberculous agents, delivered by European humanitarian organizations and their Russian colleagues.3

For many, the therapy is ineffective because the strains of TB that are epidemic within the prisons are resistant to the drugs being administered. Various observers, including some from international human rights organizations, have averred that these prisoners have "untreatable forms" of TB, even though treatment with the standard of care used elsewhere in Europe and in North America can cure the great majority of such cases.4 TB has again become the leading cause of death among Russian prisoners-even among those receiving treatment. Similar situations may be found throughout the former Soviet Union.

Are human rights violated in this dismal scenario? Conventional views of human rights would lead one to focus on a single violation: prolonged pretrial detention, which currently has the accused detained for up to a year before making a court appearance. In many documented cases, young detainees died of prison-acquired TB before their cases ever went to trial. Such detention is in clear violation not only of Russian law, but of several human rights charters to which the country is signatory. And Russian and international human rights activists have indeed focused on this problem, demanding that all detainees be brought quickly to trial. An impasse is quickly reached when the under-funded Russian courts wearily respond that they are working as fast as they can. The Ministry of Justice agrees and is now interested in amnesty for prisoners and alternatives to imprisonment.

But let us reconsider TB in Russian prisons as a question of social and economic rights. Such an exercise yields a far longer list of violations-and a longer list of possible interventions. First, as noted, pretrial detention is illegally prolonged, and conditions are deplorable. The directors of the former gulag do not dispute this point. The head of the federal penitentiary system, speaking to Amnesty International, described the prisoners as living in "conditions amounting to torture."5 Some of the more astute prison administrators remind their critics that the dismantling of the Soviet economy has led to a sharp rise in petty crime-"People now have to steal for food," in the words of one official 6-which has swamped the prison system even as "economic restructuring" planned with the help of Western economic advisors has slashed budgets for prison health.7

Second, the detainees are subjected to conditions in which they are guaranteed increased exposure to multidrug-resistant strains of TB (MDR-TB). In other words, increased TB risks should be seen as a violation of rights; TB, as a form of punishment.8 This is due to overcrowding, ineffective infection control measures, tardy diagnosis, and ineffective or interrupted treatment of the disease once diagnosed.

Third, the prisoners are denied not only adequate food but also medical care. But again, where does the blame lie? Interview medical staff in these prisons and you will find them distraught about the funding cuts that have followed the restructuring and collapse of the Russian economy. In the words of one physician: "I have spent my entire medical career caring for prisoners with TB. And although we complained about shortages in the eighties, we had no idea how good we had it then. Now it's a daily struggle for food, drugs, lab supplies, and even heat and electricity."9

Fourth, prisoners are dying of ineffectively treated MDR-TB. Article 27 of the Universal Declaration of Human Rights, which insists that everyone has a right "to share in scientific advancement and its benefits," would have us raise questions about the fact that representatives of wealthy donor nations-relief workers-are giving prisoners drugs to which their infecting TB strains have documented resistance. Thus are the rights of the prisoners violated by the logic of cost-efficacy, which says that the appropriate drugs are too expensive for use in "the developing world," to which postperestroika Russia has been demoted. All the prison rights activism in the world will come to naught if prisoners are guaranteed the right to treatment but given the wrong prescription. In short, conventional legal views on recrudescent TB in Russian prisons fail to recognize much of the problem.

As complicated as this picture is, even more complicated are the competing explanations offered by various actors on the scene. Some international health experts insist that the heart of the problem lies with Russian physicians, who have failed to adopt modern approaches to TB control.10 Others, basing their arguments on technical or cost-efficacy grounds, argue that MDR-TB is untreatable in such settings. Experts from the international public health community have argued that it is not necessary to treat MDR-TB-the "untreatable form" in question-in this region, because the necessary second-line drugs are too expensive. These experts argue that all patients should be treated with the same doses of the same drugs and that MDR-TB would disappear if such strategies were adopted.11 Other experts, both Russian and international, have claimed that the reason for poor treatment outcomes lies with the prisoners, who are said to refuse treatment.12

How many of these claims are true? First, it seems an immodest claim of causality to lay the blame for a burgeoning TB epidemic on Russia's hapless TB specialists, given that the nation's public health infra-structure has crumbled because of economic restructuring rather than ill-advised clinical management strategies. Second, cost-efficacy arguments against treating drug-resistant TB almost always fail to note that most of the drugs necessary for such treatment have been off-patent for years. Also incorrect is the claim that MDR-TB is untreatable. My colleagues and I have done work in Peru and Haiti showing that MDR-TB can be cured in resource-poor settings.13 We also know from painful experience in New York prisons that failure to identify and treat MDR-TB will lead to outbreaks of disease throughout the prison system, and thence on to the public hospitals and beyond. Claims that the problem would be eliminated by low-cost, short-course chemotherapy are thus dangerously incorrect.14

There is reason to suspect that the other assertion, that prisoners refuse treatment, is also false. How might this claim be assessed? One option would be to ask the concerned parties. "How many of you," I asked one group of Siberian prisoners with TB, "want to be treated?" All hands went up. "Why, then, is it so widely rumored that you refuse treatment?" "Hearsay," came one quick reply. "Just not true," came another. "But we want treatment that will cure us."

Clearly, the veracity of competing claims about a matter as delicate as epidemic MDR-TB cannot be assessed by a show of hands. MDR-TB in Russian prisons is an example of a complex human rights problem that requires the application of epidemiology, subspecialty clinical medicine, and a critical sociology of knowledge. The social sciences can help to reveal the immodest claims of causality that fill any explanatory void. Facile claims about the nature of excess deaths among prisoners are to be expected; such claims are patterned and predictable. The analysis also calls for an international political economy of relief work-that is, a critical look, from a political science perspective, at the way in which humanitarian work is conducted.

But what, more specifically, does the focus on health bring to the struggle for human rights? In this article I argue that an exclusive focus on a legal approach to health and human rights can obscure the nature of violations, thereby hobbling our best responses to them. Casting prison-based TB epidemics in terms of social and economic rights offers an entrée for public health and medicine, an important step in the process that could halt these epidemics. Conversely, failure to consider social and economic rights can prevent the allied health professions and the social sciences from making a significant contribution to the struggle for human rights.

Public health and access to medical care are social and economic rights; they are every bit as critical as civil rights. One of the great ironies of the global era, in which public health has increasingly sacrificed equity for efficacy, has been the rejection by the poor of separate standards of care. In our professional journals, these subaltern voices have been heard most clearly with regard to access to antiviral therapy for HIV disease, but the destitute sick are increasingly clear on one point: promoting social and economic rights is the key goal for health and human rights in the 21st century.

I will not discuss, except in passing and to set the stage, the covenants and conventions that constitute the key documents of the human rights movement. The goal of this article is to raise, and to answer, some questions relevant to health and human rights, and in so doing to identify promising directions for future work in this field.

Allow me to say at the outset that although I am an anthropologist, I do not embrace the rigidly particularist and relativist tendencies popularly associated with the discipline.15 That is, I believe that violations of human dignity are not to be dismissed merely because they are buttressed by local ideology or long-standing tradition. But anthropology-in common with sociologic and historical perspectives in general-allows us to place in broader contexts both human rights abuses and the discourses (and other responses) they generate.16 Furthermore, these disciplines permit us to ground our understanding of human rights violations in broader analyses of power and social inequality. Whereas a purely legal view of human rights tends to obscure the dynamics of human rights violations, the contextualizing disciplines reveal them to be "pathologies of power." Social inequalities based on race or ethnicity, gender, religious creed, and-above all-social class are the motive force behind most human rights violations. In other words, violence against individuals is usually embedded in entrenched "structural violence."17

In exploring the relationships between structural violence and human rights, I will also draw on my own experience serving the destitute sick in settings such as Haiti and Chiapas, where human rights violations are a daily concern; I have already discussed Russia, where increasing structural violence is not yet recognized as a human rights issue. I do this not to make too much of my personal acquaintance with other people's suffering, but rather to ground a theoretical discussion in the very real experiences that have shaped my views on health and human rights. Each of these situations calls not only for our recognition of the relationship between structural violence and human rights violations, but also for what might be termed pragmatic solidarity: the rapid deployment of our tools and resources to improve the health of those who are victimized by this violence.

The field of health and human rights, most would agree, is in its infancy. Attempting to define a new field is necessarily a treacherous enterprise: sometimes we appear to step on the toes of those who have long been at work when we mean instead to stand on their shoulders. Human rights law, which focuses on civil and legal rights, is much older than human rights medicine. And if vigor is assessed in the typical academic style-by length of bibliography-human rights law is the more robust field, too. That legal documents and scholarship dominate the human rights literature is unsurprising, note Steiner and Alston, given that the human rights movement has "struggled to assume so law-like a character."18

Even in legal terms, the international human rights movement is essentially a modern phenomenon, beginning, some argue, with the Nuremberg trials.19 It is this movement that has led, most recently, to the constitution of international tribunals to judge war crimes in the Balkans and in Rwanda. It is 50 years after the Universal Declaration of Human Rights, 50 years after the 4 Geneva Conventions. What do we have to show for these efforts? Do we have some sense of outcomes? Aryeh Neier, former executive director of Human Rights Watch, recently reviewed the history of various treaties and covenants from Nuremberg to the Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. "Nations have honored these obligations," he concludes, "largely in the breach."20

Certainly, it would be difficult to correlate a steep rise in the publication of human rights documents with a statistically significant drop in the number of human rights abuses. Rosalyn Higgins says pointedly (emphasis in the original):

No one doubts that there exists a norm prohibiting torture. No state denies the existence of such a norm; and, indeed, it is widely recognized as a customary rule of international law by national courts. But it is equally clear from, for example, the reports of Amnesty International, that the great majority of states systematically engage in torture. If one takes the view that noncompliance is relevant to the retention of normative quality, are we to conclude that there is not really any prohibition of torture under customary international law?21

Whether these laws are binding or largely hortatory constitutes a substantial debate in the legal literature, but such debates seem academic in the face of overwhelming evidence of persistent abuses. When we expand the concept of rights to include social and economic rights, the gap between the ideal and reality is even wider.

Local and global inequalities mean that the fruits of medical and scientific advances are stockpiled for some and denied to others. The dimensions of this inequality are staggering, and the trends are bad. To cite just a few examples: by 1995, the total wealth of the top 358 "global billionaires" equaled the combined income of the world's 2.3 billion poorest people.22 In 1998, Michael Jordan earned from Nike the equivalent of 60 000 years' salary for an Indonesian footwear assembly worker. Haitian factory workers, most of them women, make 28 cents per hour sewing Pocohantas pajamas, while Disney's US-based chief executive officer makes $97 000 for each hour he toils.23

The pathogenic effects of such inequality per se are now recognized.24 Many governments, including our own, refuse to redress inequalities in health, while others are largely powerless to address them.25 But although the reasons for failure are many and varied, even optimists allow that these charters and covenants have not brought an end to-and may not even have slowed-egregious abuses of human rights, however they are defined. States large and small violate civil, economic, and social rights, and inequality both prompts and covers these violations.

There are, of course, exceptions; victories have been declared. But none of them are very encouraging on close scrutiny. Haiti, the case I know best, offers a humbling example. First, the struggle for social and economic rights in Haiti has been dealt lethal blows. Such basic entitlements, the centerpiece of the popular movement that in 1990 brought the first democratically elected president to power, were buried under an avalanche of human rights violations after the military coup of 1991. And although human rights groups were among those credited with helping to restore constitutional rule in Haiti, this was accomplished, to a large extent, by sacrificing the struggle for social and economic rights.26 Today, the steam has also run out of the movement to bring to justice those responsible for the murder and mayhem that have made Haiti such a difficult place to live.

Or take Argentina, considered by some to be a successful chapter in the struggle against impunity. The gruesome details of the "dirty war" are familiar to many.27 Seeking what Aryeh Neier has chillingly termed "a better mousetrap of repression," the Argentine military government began "disappearing" (as Latin Americans said in the special syntax crafted for the occasion) people it identified as leftists.28 Many people know, now, about the death flights that took place every Wednesday for 2 years: thousands of citizens the government deemed subversive, many of them students and most of them having survived torture, were flown from a military installation out over the Atlantic, stripped, and shoved out of the plane. A better mousetrap, indeed.

What happened next is well documented, although it is a classic instance of the half-empty, half-full glass. Those who say the glass is half-full note that an elected civilian government subsequently tried and convicted high-ranking military figures, including the generals who spelled one another in the presidential office. Those who say the glass is half-empty note that the prompt pardoning and release of the criminals meant that, once again, no one was held accountable for thousands of murders.29 Similar stories abound in Guatemala, El Salvador, the state of Chiapas in Mexico, and elsewhere in Latin America, as the record shows.30

These painful experiences are, of course, no reason to declare legal proceedings ineffective. On the contrary, they remind us that what was previously hidden away is now more out in the open. Disclosure is often the first step in the struggle against impunity, and human rights organizations-almost all of them nongovernmental-have at times forced unwilling governments to acknowledge what really happened. These efforts should serve as a rallying cry for those who now look to constitute international criminal tribunals.

Still, the results to date suggest that we would be unwise to put all of our eggs in the legal-struggle basket. Complementary strategies and new openings are critically needed. The health and human rights "angle" can provide new opportunities and new strategies at the same time that it lends strength to a movement sorely in need of buttressing.

A few years ago, the French sociologist Pierre Bourdieu and his colleagues pulled together a compendium of testimonies from those the French term "the excluded" in order to bring into relief la misère du monde. Bourdieu and colleagues qualify their claims for the role of scholarship in addressing this misery: "To subject to scrutiny the mechanisms which render life painful, even untenable, is not to neutralize them; to bring to light contradictions is not to resolve them."31

It is difficult to merely study human rights abuses. We know with certainty that rights are being abused at this very moment. And the fact that we study, rather than endure, these abuses is a reminder that we too are implicated in and benefit from the increasingly global structures that determine, to an important extent, the nature and distribution of assaults on dignity.

Ivory-tower engagement with health and human rights can, often enough, reduce us to seminar-room warriors. At worst, we stand revealed as the hypocrites that our critics in many parts of the world have not hesitated to call us. Anthropologists have long been familiar with these critiques; specialists in international health, including AIDS researchers, have recently had a crash course.32 It is possible, usually, to drown out the voices of those demanding that we stop studying them, even when they go to great lengths to make sure we get the message. Social scientists have documented a rich trove of graffiti, songs, demonstrations, tracts, and broadsides on the subject. A hit record album in Haiti was called International Organizations. The title cut includes the following lines: "International organizations are not on our side. They're there to help the thieves rob and devour.... International health stays on the sidelines of our struggle."

In the context of long-standing international support for sundry Haitian dictatorships, one could readily see the gripe with international organizations. The international community's extraordinary largesse to the Duvalier regime has certainly been well documented.33 Subsequent patterns of giving, relying as they did on sundry Duvalierist military juntas, did nothing to improve the reputation of US foreign aid or the international organizations. Such critiques are not specific to Haiti, although Haitians have pronounced them with exceptional frankness and richness of detail. These accusations have been echoed and amplified throughout what some are beginning to call the global geoculture.34 A full decade before the AIDS research debates of the past year, it was possible to collect a bookful of such commentary.35

It is in this context of globalization, "mediatization," and growing inequality that we are forging the new field of health and human rights. These contextual factors are particularly salient when we think about social and economic rights, as Steiner and Alston have noted: "An examination of the concept of the right to development and its implications in the 1990s cannot avoid consideration of the effects of the globalization of the economy and the consequences of the near-universal embrace of the market economy."36 It is in this context that we must define our research agenda. We are leaving behind the terra firma of double-blinded, placebo-controlled studies, of cost-efficacy, and of sustainability.

What, then, is the role of the First World university, of researchers and health care professionals, in all of this? We can agree, perhaps, that these centers are places from which to conduct research, to document, and to teach. A university does not have the same obligations or constraints as an international institution such as the United Nations, or as organizations such as Amnesty International or Physicians for Human Rights. Such institutions afford a unique and privileged space in which to conduct research and engage in critical assessment.

In human rights work, however, research and critical assessment are necessary but not sufficient. No more adequate, for all their virtues, are denunciation and exhortation, whether in the form of press conferences or reports or harangues directed at students. To confront, as an observer, ongoing abuses of human rights is to be faced with a moral dilemma. The increasingly baroque codes of research ethics generated by institutional review boards will not help us out of this dilemma, nor will medical ethics, which are lost, so often, in the quandary ethics of the individual. But certain models of engagement are not irrelevant. If the university-based human rights worker is in a peculiar position, it is not entirely unlike that of the clinician researcher. Both study suffering; both are bound to relieve it; neither is in possession of a tried-and-true remedy. Both the human rights specialist and the clinician researcher have blind spots, too.

To push the analogy further, it could be argued that there are, in both lines of work, obligations regarding the standard of care. Once a reasonably effective intervention has been identified, it-and not placebo-is considered the standard against which a new remedy must be tested. Of course, pushing for higher standards for the victims is always a utopian enterprise. Many factors may limit feasibility, but that didn't stop the authors of the Universal Declaration from setting high goals. That we have failed to meet them does not imply that the next step is to lower our sights, although this has been the default logic in many instances. The next step is to try new approaches and to hedge our bets with indisputably effective interventions.

Providing pragmatic services to the afflicted is one obvious response to the critiques that we ignore at our peril. In other words, social and economic rights cannot be excluded from the campaign for health and human rights. Again, my own experience in Haiti, which began in 1983, made this clear. The Duvalier dictatorship was then in power, seemingly immovable. Its chief source of external financial aid was the United States and various international institutions, many of them ostensibly charitable in nature. The local director of the United States Agency for International Development at the time had often opined that if Haiti was underdeveloped, the causes were to be sought in Haitian culture.37 Popular cynicism regarding these transnational institutions was at its peak when my colleagues and I began working in Haiti, and that is precisely why we chose to work through community-based organizations and for a group of rural peasants who had been dispossessed of their land. Although we conducted research and published it, research did not figure on the wish list of the people we were trying to serve. Services were what they asked for, and as people who had been displaced by political and economic violence, they regarded these services as the rightful remedy for what they had suffered. In other words, social and economic rights were deemed central to the Haitian struggle for human rights.

The same has been true of the struggle in Chiapas. The Zapatista rebellion was launched on the day the North American Free Trade Agreement was signed, and the initial statement of the rebellion's leaders put their demands in terms of social and economic rights:

We are denied the most elementary education so that they can use us as cannon fodder and plunder our county's riches, uncaring that we are dying of hunger and curable diseases. Nor do they care that we have nothing, absolutely nothing, no decent roof over our heads, no land, no work, no health, no food, no education. We do not have the right to freely and democratically elect our own authorities, nor do we have peace or justice for ourselves and our children.38

It is in settings such as these that we must decide how health professionals might make common cause with the destitute sick, whose rights are violated daily. Helping governments shore up failing public health systems may or may not be wise. In Chiapas, for example, many communities simply refuse to use government health services. In village after village, we heard the same story. To quote one health worker, "The government uses health services against us. They persecute us if they think we are on the side of the rebels." In some "autonomous zones," the Mexican Army-one third of which, or 70,000 troops, is now stationed in Chiapas-has entered these villages and destroyed health records and what meager infrastructure had been developed. Our own investigations have been amply confirmed by others, including Physicians for Human Rights:

At best, [Mexican] Government health and other services are subordinate to Government counterinsurgency efforts. At worst, these services are themselves components of repression, manipulated to reward supporters and to penalize and demoralize dissenters. In either case, Government health services in the zone are discriminatory, exacerbate political divisions, and fail utterly to address the real health needs of the population.39

If we accept the need to think in both theoretical and instrumental terms, there is a difference, in human rights work, between analysis and strategy. Failure to recognize this difference has often hobbled interventions designed to prevent or allay human rights violations. In this arena, analysis means bringing out the truth, no matter how clumsy or embarrassing or inexpedient. It means documenting, as Aryeh Neier recently put it, "Who did what to whom, and when?" Strategy asks a different question: What is to be done?

For example, high-minded charters are utopian strategies that may become laws to be flouted or obeyed; they are not analysis. The notion that everyone shares the risk of having his or her rights violated is reminiscent of catchy public health slogans such as "AIDS is for everyone." These slogans may be useful for social marketing, but they are redolent of the most soft-headed thinking. The distribution of AIDS is strikingly patterned; so is that of human rights abuses. There is considerable overlap between the groups at risk: if you are likely to be tortured or otherwise abused, you are also likely to be in the AIDS risk group composed of the poor and the defenseless.40

Human rights can and should be declared universal, but the risk of having one's rights violated is not universal. Moreover, not every offense should be automatically classed as a human rights violation. Sticks and stones, we know, may break bones; but although it is not true that "names will never hurt me," there is wisdom in this adage. The often parochial identity politics of our time and place have indeed sought to extend the reach of rights language. But the risk of such universalization of the concept of rights is that obscene inequalities of risk will be drowned in a rising tide of petty complaint.41

Only careful comparative analysis gives us a sense of scale; only careful analysis brings mechanisms into relief. We have seen brisk debate about a hierarchy of human rights abuses and about whether or not it makes sense to consider some rights "fundamental." The struggle for recognition of social and economic rights has engendered even more acrimony.42 But this debate has been legal in nature-centered in and destined toward law, where it is customary to speak of inalienable rights and to wait decades or centuries to see them vindicated. The public health and medical communities are accustomed to triage and to assessment of gravity; it makes sense, in my view, to distinguish between the harm done by receiving 6 lashes for vandalism-when meted out to a US citizen abroad, a cause célèbre, to judge by inches of newspaper copy-and that done by a lifetime of institutionalized racism.43 It makes sense to distinguish between a struggle for access to control of power-breaking the gendered "glass ceiling" of transnational corporations, say-and access to basic primary health care, especially if these same corporations can be shown to be linked to deepening inequity between rich and poor. To make distinctions between genocide and censorship of intellectuals is not to declare the latter trivial. But our job of telling the truth as best we can compels us to weight those wrongs differently.

Merely telling the truth, of course, often calls for exhaustive research. In the 20th century, human rights violations are usually both local and global; telling who did what to whom and when becomes a complicated affair. Take the case of Chouchou Louis, a young man tortured to death in Haiti in early 1992. I have told his story elsewhere in lurid detail; here I will say merely that I was called to see him after he was cast out of police headquarters to die in the street. He did just that: I was too late, too unequipped, medically, to save his life. Documenting what had happened to him was the least I could do.

Was I to document only the "distal" events? Although all present were terrified, it was possible to obtain the names of those who arrested and tortured Chouchou Louis. But the chain of command, I learned, kept reaching higher. At the time, US officialdom's explanation of human rights abuses in Haiti, including the torture and murder of people like Chouchou Louis, focused almost exclusively on local actors and local factors. One heard of the "culture of violence" that rendered this and similarly grisly deaths comprehensible. Such official analyses, constructed through the conflation of structural violence and cultural difference, were distancing tactics.

Innumerable immodest claims of causality, such as attributing a sudden upsurge in torture of persons in police custody to longstanding local custom, play into the convenient alibi that refuses to follow the chain of events to their source, that keeps all the trouble local. Such alibis obscure the fact that the modern Haitian military was created by an act of the US Congress during our 20-year occupation (1915-1934) of Haiti. These analyses did not discuss generous US assistance to the post-Duvalier military: over $200 million in aid passed through the hands of the Haitian military in the 18 months after Jean-Claude Duvalier left Haiti on a US cargo plane in 1986. Bush administration statements, and their faithful echoes in the establishment press, failed to mention that many of the commanders who issued the orders to detain and torture were trained in Fort Benning, Georgia.44

The masking of the mechanisms of human rights violations is seen elsewhere. When my coworkers and I visited autonomous communities in Chiapas in November 1997, it was clear that paramilitary groups linked tightly with the Mexican government were responsible for the bulk of intimidation and violence in these villages.45 But, as in Haiti, federal authorities insisted that such violence was due to "local inter-community and interparty tension" or to ethnic rivalry.46

Immodest claims of causality are not always so flagrantly self-serving as those proffered to explain Haiti's agony or the violence in Chiapas. But only careful analysis allows us to rebut them with any confidence.

Medicine and public health, and also the social sciences relevant to these disciplines, have much to contribute to the great, often rancorous debates on human rights. But what, precisely, might be our greatest contribution? Rudolph Virchow saw doctors as "the natural attorneys of the poor."47 A "health angle" can promote a broader human rights agenda in unique ways. In fact, the health part of the formula may prove critical to the success of the human rights movement. The honor in which public health and medicine are held affords us openings-again, a space of privilege-enjoyed by few other professions. For example, it is unlikely that my colleagues and I would have been welcomed so warmly into Russian prisons as social scientists or as human rights investigators. We went, instead, as TB specialists, and we suspected, without egotism, that a visiting group of doctors might be able to do more for the rights of these prisoners than a delegation from a conventional human rights organization. It is important to get the story straight: the leading cause of death among young Russian detainees is TB, not torture or starvation.

Medicine benefits from an extraordinary symbolic capital that is, so far, sadly underutilized in human rights work. No one made this point more clearly and persistently than the late Jonathan Mann. In an essay written with Daniel Tarantola, Mann noted that AIDS "has helped catalyze the modern health and human rights movement, which leads far beyond AIDS, for it considers that promoting and protecting health and promoting and protecting human rights are inextricably connected."48

But have we gone far beyond AIDS? Is it not a human rights issue that Russian prisoners are exposed, often during illegally prolonged pretrial detention, to epidemic MDR-TB and then denied effective treatment? Is it not a human rights issue that international expert opinion has mistakenly informed Russian prison officials that treatment with second-line drugs is not cost-effective or that it is just plain unnecessary?

Standing on the shoulders of giants-from the authors of the Universal Declaration to Jonathan Mann-we can recognize prison epidemics as human rights issues. But what, precisely, is to be done? Russian penal codes already prohibit overcrowding, long pretrial detention, and undue risk from malnutrition and communicable disease. Prison officials already regard the TB problem as a top priority; that's why they let TB specialists in there. In a recent interview, one high-ranking prison official told me that the ministry saw their chief problems as lack of resources, overcrowding, and TB.49 And the pièce de résistance might be that Boris Yeltsin had already declared 1998 "the year of human rights."

The Haitian military coup leaders were beyond the pale. But how about Chiapas? Instruments to which Mexico is already signatory include the Geneva Conventions of 1949; the International Covenant on Civil and Political Rights; the International Covenant on Economic, Social and Cultural Rights; the International Labor Organization Convention 169; the American Convention on Human Rights; the Maastricht Guidelines on Violations of Economic, Social and Cultural Rights; and the Convention on the Elimination of All Forms of Discrimination Against Women. Each of these is flouted each day in Chiapas.

As the Haitians say, "Laws are made of paper; bayonets are made of steel." The law alone is not up to the tasks of relieving such immense suffering. Louis Henkin has reminded us that international law is fundamentally a set of rules and norms designed to protect the interests of states, not their citizens. "Until recently," he observed in 1989, "international law took no note of individual human beings."50 And states, as we have seen, honor human rights law largely in the breach-sometimes through intention, and sometimes through sheer impotence. This chief irony of human rights work-that states will not or cannot obey the treaties to which they are signatory-can lead to despair or to cynicism, if all one's eggs are in the international-law basket.

Laws are not science; they are normative ideology, and tightly tied to power.51 Biomedicine and public health, though also vulnerable to ideological deformations, serve different imperatives, ask different questions. They do not ask whether an event or process violates an existing rule; they ask whether that event or process can be shown to have ill effects on a patient or on a population. They ask whether such events can be prevented or remediated. This approach would have, I would argue, a salutary effect on many human rights debates.

To return to the case of prisoners with MDR-TB, the best way to protect their rights is to cure them of their disease; the best way to protect the rights of other prisoners is to prevent transmission by treating the sick. A variety of strategies, from human rights arguments to epidemiologic scare tactics, have been used to make headway in raising the funds necessary to treat these and other prisoners. In the end, then, the health angle on human rights may prove more pragmatic than approaching the problem as one of penal reform alone. Previously closed institutions have opened their doors to international collaboration designed to halt prison epidemics. This approach-pragmatic solidarity-may lead to penal reform as well. I will return to this approach in proposing new agendas for health and human rights, but proceed under the assumption that there are many pitfalls-moral, strategic, and analytic-to any approach to human rights that regards research as an end in and of itself.52

To summarize the argument so far: We have a long way to go in the struggle for health and human rights; it isn't really possible to merely study the topic without meaningful and pragmatic interventions; it is important to distinguish between our best analysis and our best strategies; and the health angle offers a critical new dimension to human rights work and is still a largely untapped vein of resources and passion and goodwill.

What about new agendas? First, is it grandiose to seek to define new agendas? When one reads the powerfully worded statutes, conventions, treaties, and charters stemming from international revulsion over the crimes of the Third Reich, it would seem pointless to call for better instruments of this sort. Yet events in the former Yugoslavia and in Rwanda serve as a powerful rebuke to undue confidence in these approaches: "That it should nevertheless be possible for Nazi-like crimes to be repeated half a century later in full view of the whole world," remarks Aryeh Neier, "points up the weakness of that system-and the need for fresh approaches."53 Steiner and Alston, similarly, call for "heightened attention to the problems of implementation and enforcement of the new ideal norms. The old techniques," they conclude, "simply won't work."54

A corollary question, then: Does a coherent agenda spring from the critique inherent in the answers to the questions presented here? If so, is this agenda compatible with existing approaches and documents, including the Universal Declaration of Human Rights? To those who believe that social and economic rights must be central to the health and human rights agenda, the answers to these questions are "Yes" and "Of course, yes." This agenda is coherent, pragmatic, and informed by careful scholarship. It builds on 5 decades of work within the traditional human rights framework: articles 25 and 27 of the Universal Declaration inspire the vision of this emerging agenda, which would rely on tighter links between universities, medical providers, and both nongovernmental and community-based organizations.

How might we proceed with this effort, if most reviews of the effects of international laws and treaties designed to protect human rights raise serious questions of efficacy, to say the least? What can be done to advance new agendas of health and human rights? I offer 6 suggestions, which are intended to complement ongoing efforts.

If we make health and healing the symbolic core of the agenda, we tap into something truly universal-concern for the sick- and, at the same time, engage medicine, public health, and the allied health professions, including the basic sciences. Although many global health indicators show significant improvement, we still have endless work to do before we can claim to have made the slightest headway in ensuring the highest possible level of health for all. In fact, several studies suggest that inequalities in health outcomes are growing in many places.55

Put another way, we need to throw the full weight of the medical and scientific communities behind a noble cause. There is no hostility, in these communities, to this cause; quite the contrary. What has been lacking, with some notable exceptions (such as Physicians for Human Rights) has been concerted efforts to engage health professionals in human rights work.

We need to listen to the sick and abused and to those most likely to have their rights violated. Whether they are nearby or far away, we know, often enough, who they are. The abused offer, to those willing to listen, critiques far sharper than my own. They are not asking for new centers of study and reflection. They have not commissioned new studies of their suffering. That means we need new programs in addition to the traditional ventures of a university or a research center (journals, books, articles, courses, conferences, research). Law schools have clinics, and so do medical schools. Programs promoting health and human rights should not have only legal clinics. With help from a broad range of health professionals, it would be possible to establish, for example, referral clinics for those subjected to torture and other human rights abuses as classically defined.

But a far larger group calls for our pragmatic solidarity. We need to hedge our moral bets with programs designed to remediate inequalities of access. If everyone has a right "to share in scientific advancement and its benefits," where are our pragmatic efforts to improve the spread of these advances? Such efforts exist, but, again, the widening "outcome gap" stands as the sharpest rebuke to the health and human rights community: even as our biomedical interventions become more effective, our capacity to distribute them equitably is further eroded. The world's poor and otherwise marginalized people currently constitute a vast control group of the untreated, and even cursory examination of the annual tally of victims reminds us that this sector also constitutes the group most likely to have their rights violated.

How can we make services-pragmatic solidarity-central to the work of health and human rights programs? Our own group, Partners in Health, has worked largely with community-based organizations in Haiti and Peru whose express goal has been to remediate inequalities of access. This community of providers and scholars believes that "the vitality of practice" lends a corrective strength to our research and writing.56 The possibilities for programmatic collaboration range, we have learned, from Russian prison officials to peasant collectives in the autonomous zones of Chiapas. In Chiapas, it is possible to hedge bets by supporting health promoters working within autonomous zones, which have been singled out for particularly brutal reprisals for alleged support of rebels. Novel collaborations of this sort are certainly necessary if we are to address the increasing inequalities of access here in wealthy, inegalitarian countries such as the United States. Relying exclusively on nation-states' compliance with a social-justice agenda is naive at best.

These questions of new collaboration are raised at a time of increasing globalization, yet our action agenda has stayed parochial. We lag behind trade and finance, since we are still at the first steps in the press for universal rights while the "masters of the universe" are already "harmonizing" their own standards and practices. Fifteen years of work in the most difficult field conditions have taught my group that it is difficult, perhaps impossible, to meet the highest standards of health care in every situation. But it is an excellent idea to try to do so. Projects striving for excellence-rather than, say, "cost-efficacy" or "sustainability," which are often at odds with social-justice approaches to medicine and public health-are not merely misguided quests for personal efficacy. Such projects respond to widespread demands for equity in health care. The din around AIDS research in the Third World is merely the latest manifestation of a rejection of low standards as official policy. That these are widely seen as violating human rights is no surprise for those interested in social and economic rights. Efficacy cannot trump equity in the field of health and human rights.

We need to make room in the academy for serious scholarly work on the multiple dynamics of health and human rights, on the health effects of war and political-economic disruption, and on the pathogenic effects of social inequalities, including racism, gender inequality, and the growing gap between rich and poor. By what mechanisms, precisely, do such noxious events and processes become embodied as adverse health outcomes? Why are some at risk and others spared?

Here again, we lag far behind. As Nancy Krieger notes, "epidemiologic research explicitly focused on discrimination as a determinant of population health is in its infancy."57 To answer the questions posed above, we require a new level of cooperation between disciplines ranging from social anthropology to molecular epidemiology. We need a new sociology of knowledge that can pick apart a wide body of commentary and scholarship: complex international law; the claims and disclaimers of officialdom; postmodern relativist readings of suffering; clinical and epidemiologic studies of the long-term effects of, say, torture.58 And because such research would be linked to service, we need operational research by which we can gauge the efficacy of interventions quite different from those measured in the past.

Human rights work usually has a suasive component. If the primary objective is to set things right, education is central to our task. But the educational mandate should not be conventional in either of the 2 most likely ways: we must not limit ourselves to teaching a select group of students with an avowed interest in health and human rights, nor must we limit ourselves to trying to teach lessons to recalcitrant governments. Jonathan Mann signaled to us the limitations of the latter approach: "Support for human rights-based action to promote health...at the level of declarations and speeches is welcome, and useful in some ways, but the limits of official organizational support for the call for societal transformation inherent in human rights promotion must be recognized."59 A broader educational mandate would mean engaging students from all faculties, but also, as noted, engaging the members of these faculties. Beyond the university and various governmental bodies lies the broader public, for whom the connections between health and human rights have not even been traced.

We need to be untrammeled by obligations to powerful states and international bureaucracies. What is the central irony of human rights law? That it consists largely of appeals to the perpetrators. After all, most crimes against human rights are committed by states, not by rogue factions or gangs or cults or terrorists. That makes it difficult for institutions accountable to states to take their constituents to task. When in 1994 the UN created the post of High Commissioner for Human Rights, the $700 000 annual budget was paltry even by the standards of a nongovernmental organization. The results were predictable: "With denunciation of those responsible for abuses the only means available for carrying out his mission," the first commissioner "managed to go through his first year in his post without publicly criticizing a single government anywhere in the world."60 In Chiapas, the displacement and massacre of presumed Zapatista supporters by paramilitary groups tightly tied to the government has been documented by numerous observers: "State and federal authorities have permitted these groups to act with impunity, and state Public Security Police have not only failed to protect victims, but have sometimes participated in the evictions."61

In the end, university- and hospital-based programs may hope to be, along with the efforts of nongovernmental organizations, independent, well designed, pragmatic, and feasible. The imprimatur of medicine and public health would afford even more weight and independence. And only a failure of imagination has led us to ignore the potential of collaboration with community-based organizations and with communities in resistance to ongoing violations of human rights.

"Growth is wildly uneven, inequality is immense, anxiety is endemic," says Todd Gitlin of our era. "The state, as a result, is continually urged to do more but deprived of the means to do so."62 The halting but ineluctable spread of the global economy is linked to an evolving human rights irony: states become less able to help their citizens attain social and economic rights, even though they retain, often enough, their ability to violate human rights. Even where reforms have led to the enjoyment of basic political rights, the right to freedom from want may be eroded as new economic policies are implemented. This is particularly true of many developing countries, as Steiner and Alston note:

Civil and political rights have been greatly strengthened in many countries. Nonetheless, related contemporary phenomena-including privatization, deregulation, the expanded provision of incentives to entrepreneurial behavior, structural adjustment programs and related pressures from international financial institutions and developed countries-have had mixed, and sometimes seriously adverse, effects on the enjoyment of economic and social rights.63

Of course, it's easy to demand more resources, harder to produce them. But if social and economic rights are acknowledged as such, then foundations, governments, businesses, and international financial institutions-many of which are awash in resources-may be called to prioritize human rights endeavors that reflect the paradigm shift advocated here.

Regardless of where one stands on the process of globalization, it has important implications for efforts to promote health and human rights. As states weaken, it is easy to discern an increasing role for nongovernmental institutions, including universities and medical centers. How will we live up to the challenge to promote the highest possible level of health for all? Universities and medical centers, we have argued, should conduct research, and the subject-health and human rights-demands complementary services. Linking research to service costs money. But if we lack ambition, we should expect the next 50 years to yield a harvest of shame.

The experience of my own group suggests that ambitious goals can be met even without a large springboard. Over the past decade and against a steady current of nay-saying, we have channeled significant resources to the destitute sick in Haiti, Peru, Mexico, and Boston. We didn't argue that it was "cost-effective," nor did we promise that such efforts would be replicable. We argued that it was the right thing to do. It was the human rights thing to do.

Claims that we live in an era of limited resources fail to mention that these resources happen to be less limited now than ever before in human history. Arguing that it is too expensive to treat MDR-TB among prisoners in Russia, say, sounds nothing short of ludicrous when this world contains at least one individual worth more than $60 billion. Arguments against treating HIV disease in precisely those areas in which it exacts its greatest toll warn us that misguided notions of cost-efficacy have already trumped equity. Arguing that nominal legal rights are the best we can hope for will mean that members of the healing professions will have their hands tied. We will be forced to stand by as the rights and dignity of the poor and marginalized undergo further sustained and deadly assault.

An essay shouldn't incur a great deal of debt, unless it's about a matter of life and death. Three groups of people have helped me write this paper: friends engaged in asking hard questions about health and human rights; friends who work each day to prevent human rights abuses; and those who have endured human rights abuses. In the first category, I thank Mercedes Becerra, Didi Bertrand, Ophelia Dahl, Jennifer Furin, Howard Hiatt, Jim Yong Kim, Carole Mitnick, June Osborn, Joyce Millen, Aaron Shakow, David Walton, Noam Chomsky, Alex Goldfarb, Betty Levin, Mary Northridge, Vivien Stern, Hérnan Reyes, Mia Nitchun, Haun Saussy, and Kedar Mate. For sending me to Russia, special thanks to Aryeh Neier. The second group is too long to list, but it includes Blanca Jiménez, Loune Viaud, Titid, and coworkers from Haiti, Peru, and Chiapas. Of course, one learns bitter lessons from the sacrifice of those who have paid the ultimate price. This essay is dedicated gratefully to Armando, Chouchou, and Jean-Marie.

1. Universal Declaration of Human Rights, GA res 217A (III), UN Doc A/810 at 71 (1948). [Context Link]

2. Stern, 12. [Context Link]

3. For a more detailed depiction of these prisons, see Farmer, "TB Superbugs." [Context Link]

4. Telzak et al., 911. [Context Link]

5. Amnesty International. [Context Link]

6. Ivan Nikitovich Simonov, Chief Inspector of Prisons (now with the Chief Board of Punishment Execution), Ministry of Internal Affairs, Russian Federation; interview by author, Moscow, June 4, 1998. [Context Link]

7. Wedel, 5. [Context Link]

8. Farmer, "Cruel and Unusual." [Context Link]

9. Dr Natalya Vezhina, Medical Director, TB Colony 33, Mariinsk, Kemerovo, Russian Federation; interview by author, Mariinsk, June 1, 1998. [Context Link]

10. Dlugy. [Context Link]

11. See, for example, "Money Isn't the Issue; It's (Still) Political Will." TB Monitor. May 1998:53. [Context Link]

12. This topic is discussed in Reyes and Coninx. [Context Link]

13. Farmer, Bayona, Shin, et al. [Context Link]

14. For a rebuttal of these claims, see Farmer, Bayona, Becerra, et al. [Context Link]

15. Most anthropologists do not. Cultural relativism as a "metaethical theory" has its role and, contrary to popular belief, is not incompatible with universal values. Although I cannot review the topic here, my thinking on these matters has been informed most by my fieldwork in Haiti, but also by others in and outside anthropology. See, for example, Campbell; Geertz; Hatch; Renteln; and Schmidt. [Context Link]

16. See, for example, Asad's recent discussion of torture: "Although the phrase 'torture or cruel, inhuman, or degrading treatment' serves today as a cross-cultural criterion for making moral and legal judgements about pain and suffering, it nevertheless derives much of its operative sense historically and culturally" (285). [Context Link]

17. The concept of structural violence, and its relation to human rights, is explored in Farmer, "On Suffering and Structural Violence." [Context Link]

18. Steiner and Alston, vi. [Context Link]

19. A notable exception is to be found in the multinational mobilization against King Léopold's brutal seizure of the Congo. See Hochschild's gripping account of "the first great international human rights movement of the twentieth century" (2). [Context Link]

20. Neier, War Crimes, 75. Why are states signatory to human rights accords that they do not intend to respect? In 1989, Louis Henkin wrote: "One can only speculate as to why States accepted these norms and agreements, but it may be reasonable to doubt whether those developments authentically reflected sensitivity to human rights generally. States attended to what occurred inside another State when such happenings impinged upon their political-economic interests" (quoted in Steiner and Alston, 114). [Context Link]

21. Quoted in Steiner and Alston, 141. [Context Link]

22. Keegan. [Context Link]

23. Millen and Holtz. [Context Link]

24. On the pathogenic effects of inequality, see Farmer, "Cruel and Unusual"; Wilkinson; and Kawachi et al. A similar point was underscored in the constitution of the World Health Organization: "Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger" (July 22, 1946). [Context Link]

25. A growing number of public health practitioners and physicians have been pushing for a concerted effort to reduce inequalities in health. For a recent review, see Whitehead et al. [Context Link]

26. I am, of course, glossing a very complicated process in simple terms. The defeat of the Aristide government's social-justice agenda, which explicitly endorsed the "right to development," seemed complete by the time the Haitian government signed on to a structural adjustment project endorsed by the World Bank and the US government; see Farmer, "Significance of Haiti," for a more in-depth discussion of this process. The concept of development as a new human right, most eloquently endorsed by Judge Mohammed Bedjaoui, president of the International Court of Justice, has been hotly contested by the United States, which Steiner and Alston (1113) qualify as "an implacable opponent of the right to development." For more in-depth discussion of the relationship between human rights and structural adjustment projects, see Skogly. [Context Link]

27. Nunca Más, the report of the Alfonsín-appointed Sábato commission (Comisión Nacional Sobre la Desaparición de Personas), remains the best text on the subject. Its English translation is introduced by Ronald Dworkin, who writes of a "system of licensed sadism." See also Dussel et al., Steadman, and Ciancaglini and Granovsky. [Context Link]

28. Neier, War Crimes, 33. [Context Link]

29. This view is compellingly defended by Neier, who wonders "why the Argentine prosecution of crimes against human rights started so promisingly and why it ended so badly" ("What Should Be Done"; see also War Crimes). [Context Link]

30. For overviews, see Guillermoprieto; Chomsky; and LaFeber. [Context Link]

31. Bourdieu, 944. [Context Link]

32. For an overview of critiques of anthropology as a colonial project, see Asad. See also the essays by Hymes and by Berreman. These debates resonate with recent critiques of US-funded AIDS research in the developing world. For her comparison of placebo studies on HIV-infected mothers in Africa with the Tuskegee experiments on African Americans, New England Journal of Medicine editor Marcia Angell was taken to task by prominent figures in the scientific community (see, e.g., Varmus and Satcher), and 2 influential AIDS specialists resigned from the editorial board of the journal in protest (see Richard Saltus, "Journal Departures Reflect AIDS dispute," Boston Globe, October 16, 1997, A11). The debate continued with a front-page exploration of the ironies of US-funded AIDS research in the Ivory Coast (see Howard French, "AIDS Research in Africa: Juggling Risks and Hopes," New York Times, October 10, 1997, A1, A14). Angell justified her analogy by making a point-by-point comparison between the AIDS trials and the infamous syphilis study in "Tuskegee Revisited," Wall Street Journal, October 28, 1997, A22. [Context Link]

33. See Farmer, Uses of Haiti, and Hancock for overviews of the type and extent of international aid to these regimes. [Context Link]

34. See Wallerstein. [Context Link]

35. Farmer, AIDS and Accusation. [Context Link]

36. Steiner and Alston, 1110. [Context Link]

37. Harrison, 102. For a discussion, see Farmer, Uses of Haiti, 57. [Context Link]

38. Subcomandante Marcos, 54. [Context Link]

39. Physicians for Human Rights, 4. [Context Link]

40. Farmer, "On Suffering and Structural Violence." [Context Link]

41. This trend has already occasioned much commentary in the popular and scholarly literature. See, for example, Gitlin; Glendon; Hughes; and Jacoby. Gitlin (236) noted trenchantly that "the politics of identity is silent on the deepest sources of social misery: the devastation of the cities, the draining of resources away from the public and into the private hands of the few. It does not organize to reduce the sickening inequality between rich and poor." [Context Link]

42. See Steiner and Alston, 128-131, for an overview of the legal controversy over a hierarchy of rights. See also Alston's 1984 discussion of the proliferation of proposed rights, which have ranged from the "right to sleep" to the "right to tourism." [Context Link]

43. I refer here to the case of Michael Fay, an 18-year-old US citizen convicted of vandalizing cars and tearing down traffic signs in Singapore. According to the New York Times (April 5, 1994, A6), "Amnesty International sees the Fay case as one more reason to refocus international attention on the inhumaneness of flogging." But "many Americans," noted the article, "are surprisingly unsympathetic to the plight of the Ohio youth." The piece went on to note that letters to the editor of the Dayton Daily News, Fay's hometown newspaper, were "running against the youth," and the Singapore embassy in Washington, DC, attested that the majority of mail it received was in support of Singapore's position. [Context Link]

44. The passion of Chouchou Louis is recounted in chapter 7 of Farmer, The Uses of Haiti. Precisely the same pattern has been well documented in El Salvador and Guatemala. See chapter 5 of Uses for a comparison between these countries and Haiti. With the help of courageous colleagues in Haiti, it was possible for North Americans to work in solidarity on several levels. For example, an account of the murder of Chouchou Louis appeared under David Nyhan's name in the Boston Globe ("Murder in Haiti," March 19, 1992, A17); subsequent accounts appeared in a political magazine and in The Uses of Haiti. Pax Christi visited central Haiti in the spring of 1992 and interviewed torture victims and the families of the disappeared, including the widow of Chouchou Louis (see Pax Christi Newsletter, April 1992). The effects of the coup d'état of 1991 on the health of the local population are explored in Farmer, "Haiti's Lost Years" and "On Suffering and Structural Violence." [Context Link]

45. Farmer, "Visit to Chiapas." [Context Link]

46. Physicians for Human Rights, 4. [Context Link]

47. Virchow wrote: "For if medicine is really to accomplish its great task, it must intervene in political and social life. It must point out the hindrances that impede the normal social functioning of vital processes, and effect their removal" (48). See also Eisenberg. [Context Link]

48. Mann and Tarantola, 8. [Context Link]

49. Ivan Nikitovich Simonov, Chief Inspector of Prisons (now with the Chief Board of Punishment Execution), Ministry of Internal Affairs, Russian Federation; interview by author, Moscow, June 4, 1998. [Context Link]

50. Henkin, 1990, 208. [Context Link]

51. Oscar Schachter (6) has observed: "International law must also be seen as the product of historical experience in which power and the 'relation of forces' are determinants. Those States with power (i.e., the ability to control the outcomes contested by others) will have a disproportionate and often decisive influence in determining the content of rules and their application in practice. Because this is the case, international law, in a broad sense, both reflects and sustains the existing political order and distribution of power." Furthermore, legal commentary often reminds us of the power of normative, procedural thinking. During and after the Nuremberg trials, there was debate-again, cast in legal terms-as to whether the trials themselves were legal. Some key trial documents were published in 1947 in the American Journal of International Law: "It was urged on behalf of the defendants that a fundamental principle of all law-international and domestic-is that there can be no punishment of crime without a pre-existing law.... It was submitted that ex post facto punishment is abhorrent to the law of all civilized nations." (see International Military Tribunal [Nuremberg]. Judgment and sentences. American Journal of International Law. 1947;41[174]:19). In other words, some legalists seemed to argue that, had there been no law against genocide or "aggressive war" on the books before the fact, it was illegitimate to prosecute the Nazis for these actions. Those arguing the illegality of the Nuremberg trials were not fringe elements. Citing such concerns, Chief Justice Harlan Fiske Stone referred to the "high-grade lynching party in Nuremberg" (quoted in Mason, 746). [Context Link]

52. I do not refer here to historical investigation, which is crucial to an understanding of the dynamics of structural violence. The study of human rights abuses in the slave trade, say, is quite different from an investigation of ongoing, documentable suffering. [Context Link]

53. Neier, War Crimes, xiii. [Context Link]

54. Steiner and Alston, viii. [Context Link]

55. For a review, see Millen et al. [Context Link]

56. For an overview of this group and its "vitality of practice," see the chapter by that name in Farmer, Infections and Inequalities. [Context Link]

57. Krieger, 295. [Context Link]

58. An example of this approach is to be found in Asad's recent discussion of torture and modern human rights discourse. He notes: "If cruelty is increasingly represented in the language of rights (and especially of human rights), this is because perpetual legal struggle has now become the dominant mode of moral engagement in an interconnected, uncertain, and rapidly changing world" (304-305). [Context Link]

59. Mann, 145-146. [Context Link]

60. Neier, War Crimes, 23-24. [Context Link]

61. Physicians for Human Rights, 12. [Context Link]

62. Gitlin, 224. [Context Link]

63. Steiner and Alston, 1140. [Context Link]

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Community-Oriented Primary Care: Health Care for the 21st Century

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