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Never Again? Reflections on Human Values- Paul Farmer

Never Again? Reflections on Human Values

and Human Rights

Paul Farmer

The Tanner Lectures on Human Values

Delivered at

University of Utah

March 30, 2005

Paul Farmer is a founding director of Partners In Health, an in-ternational charity organization that provides direct health care services and undertakes research and advocacy activities on behalf of those who are sick and living in poverty. He is also Presley Professor of Medical Anthropology in the Department of Social Medicine at Harvard Medi-cal School, attending physician in infectious diseases and associate chief of the Division of Social Medicine and Health Inequalities at Brigham and Women’s Hospital in Boston, and medical director of the Clinique Bon Sauveur in Haiti. He was educated at Duke University and received his M.D. and Ph.D. from Harvard University. He is the recipient of the Margaret Mead Award from the American Anthropological Asso-ciation, the American Medical Association’s Outstanding International Physician (Nathan Davis) Award, and the Heinz Humanitarian Award. He was also awarded a ­acArthur Foundation “genius award” and is the subject of Tracy Kidder’s Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World. His numerous pub-lications include AIDS and Accusation: Haiti and the Geography of Blame (1992); The Uses of Haiti (1994); Infections and Inequalities: The Modern Plagues (1998); and Pathologies of Power: Health, Human Rights, and the New War on the Poor (2003).

To designate a hell is not, of course, to tell us anything about how to extract people from that hell, how to moderate hell’s flames. Still, it seems a good in itself to acknowledge, to have enlarged, one’s sense of how much suffering is caused by human wickedness there is in the world we share with others. Someone who is perennially surprised that depravity exists, who continues to feel disillusioned (even incredulous) when confronted with evidence of what humans are capable of inflicting in the way of gruesome, hands-on cruelties upon other humans, has not reached moral or psychological adulthood. No one after a certain age has the right to this kind of innocence, of superficial-ity, to this degree of ignorance, or amnesia.

Susan Sontag, Regarding the Pain of Others

1. Preliminaries

It is with no small amount of trepidation that I seek to reflect on “human values” as a Tanner lecturer. This trepidation comes in part from the usual sources. Because all humans have values, to claim expertise in the universal arena of value-making is necessarily a perilous activity. Argu-ments abound. Are some values truly universal, the products of growing up in a human body and within a human family of some sort or another? Or are all human values socially constructed, with no real bedrock but that we create through culture? Aren’t all values by definition human? Many ethologists and sociobiologists dispute this last point fiercely.

We are not here to join in these disputes, except to the extent that they contribute to certain human rights debates. I say “we” because this lecture will consider how photographs and stories may be used to spark reflection on human, and humane, values. And chastened by Susan Sontag’s admonition that “no ‘we’ should be taken for granted when the subject is looking at other people’s pain,” I note at the outset that

Writing an essay is necessarily trial and error, and I’ve had steering, in completing this Tanner Lecture, from Jennie Weiss Block, Wayne Cavalier, Deogratias Niyizonkiza, Beth Collins, Nancy Dorsinville, Agnès Binagwaho, and Isabella Harty-Hugues. I am especially grateful to David Walton, who is as good a photographer as he is a physician, and to Haun Saussy and Barbara Rylko-Bauer, who have, over the years, helped me to think through these difficult topics. Alice Yang provided, as ever, careful editing of both content and style.

. Susan Sontag, Regarding the Pain of Others (New York: Farrar, Strauss, and Giroux, 2003), p. 114.

. Sontag, Regarding the Pain of Others, p. 7.

[139]

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these are stories that belong to other people, not to me; the photographs were taken by me and by other physicians working with Partners In Health, a nongovernmental organization seeking to put into practice those human values that support the belief that health care should be viewed as a human right. Partners In Health has worked in rural Haiti for many years; we have also had the privilege of caring for patients in places as far-flung as Peru, Siberia, and Rwanda.

In the course of doing this work, we’ve learned a great deal about how best to deliver medical care to the very poorest, to prisoners, and to the victims of violence. This work has also taught us that those seeking to serve such patients must know something about human rights. We’ve learned, for example, that there is no single coherent “human rights movement,” but rather heterogeneous groups of people with very dif-ferent conceptions of how rights are related to values; these groups have different conceptions of how human rights and values should come into play, particularly in the course of responding to the problems of persis-tent poverty and inequality, violence, and even epidemic disease.

This diversity of opinions and our own experience working among the destitute sick have also forced us to consider the following ques-tions: should access to health care be considered a human right? If so, what kind of right is it? What is the relationship between social condi-tions and human rights? Answers to these questions are much contested within various human rights movements. There are reasons why some who do not live in poverty—for example, people who give or read lec-tures such as this one, and those who write about rights—do not always wish to see an analysis of poverty and inequality figure centrally in de-bates about human values and human rights. One reason is that the affluent share a single world with the poorest, just as the violent share a world with victims of violence and the healthy share a world with the sick. In Regarding the Pain of Others, Sontag explores human values and human rights and also the role played by photographs, reminding us that viewer and victim share the same time and space: “Being a spectator of calamities taking place in another country,” she warns, “is a quintes-sential modern experience.” But the notion that we belong to different worlds—the first and third, for example—is an illusion, one that can be conjured or shattered by photographs and stories, depending upon the

. Partners In Health is described in chapter 1 of my book Infections and Inequalities (Berkeley: University of California Press, 1999) and also on a website, www.pih.org.

. Sontag, Regarding the Pain of Others, p. 18.

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ways in which they are presented. Sontag exhorts us that “to set aside the sympathy we extend to others beset by war and murderous politics for a reflection on how our privileges are located on the same map as their suffering, and may—in ways we might prefer not to imagine—be linked to their suffering, as the wealth of some may imply the destitution of others, is a task for which the painful, stirring images supply only an initial spark.”

Proximity and connections are often the subtext of current-day dis-cussions of “globalization,” and these discussions, too, bring their own arcane debates. In this lecture we will reflect on extreme suffering as it occurs in this global web of hidden connections. If we are located on the same map as the suffering of others, how do we describe the fact that some of us are shielded from violence and epidemic disease while others are faced, from birth forward, with enormous risks? One way to trace this geography of unequal risk is to consider how “structural violence” is meted out to the poor in myriad ways. I’ve traced the history of the concept elsewhere. In the 1960s, Latin American liberation theologians used the term broadly to describe “sinful” social structures character-ized by poverty and by steep grades of social inequality, including rac-ism and gender inequality. If sinful social structures are seen as created and sustained more by the powerful than the powerless, it’s possible to argue that structural violence is violence exerted systematically—and, often enough, indirectly—by everyone who belongs to a certain social order: hence the discomfort these ideas provoke in a moral economy still geared to pinning praise or blame on individual actors rather than to revealing how social arrangements create danger, disease, and death.

Like any social concept, structural violence falls short of encompass-ing the complexity and the messy contradictions of the real world in all its real violence. For this reason, and others, the term is not without its detractors even among people who recognize the problem and the need to remedy it. Just as everyone seems to have his or her own definitions of “structure” and “violence,” so too does the term “structural violence” cause epistemological jitters among those who study social process (it is not an expression I’ve heard used in human rights debates, where it would be most useful). Scholars I much admire have taken me to task for relying on a concept that does too little to parse very different kinds of violence. Responding to a lecture I delivered in 2001, the sociologist Loïc Wacquant offered the following critique:

. Ibid., pp. 102–3.

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…the category of “structural violence” conflates full-fledged domi-nation with mere social disparity and then collapses forms of violence that need to be differentiated, such as physical, economic, political, and symbolic variants or those wielded by state, market, and other social entities. Nothing is gained by lumping under the same head-ing “steep grades of social inequality, including racism and gender inequality,” that may operate smoothly with the consent of the sub-ordinate with, say, wife beating and ethnic rioting or “brute poverty” with, say, military invasion and genocidal policies.

Wacquant concludes that “structural violence may be strategically use-ful as a rhetorical tool, but it appears conceptually limited and limiting, even crippling.” I take Wacquant’s critique to heart, in part because he is correct in calling for more carefully parsed descriptions and analyses of suffering and in part because he is correct to underline the role of such a concept as a rhetorical tool. But aren’t rhetorical tools necessary if we seek to lessen violence in all its forms? Isn’t that what photographs and personal narratives often are, rhetorical tools, when the topic is human values and human rights? How do we bring suffering into relief in a manner that would spur into action those who could change the unfair arrangements that increasingly characterize the world in which we live?

Still, no amount of rhetorical effectiveness can shout down the con-ceptual and analytic issues. There are, to be sure, many kinds of violence, and a term that attempts to bridge the social (including the historical and economic), the psychological, and the biological without making the necessary distinctions may both create an unwanted black box in the place of human motivations and leave us no way of measuring the de-grees, assessing the kinds, and forecasting the consequences of violence and rights violations. Even if, descriptively, it makes sense to say that

. Loïc Wacquant, Comment on “An Anthropology of Structural Violence” by Paul Farmer, Current Anthropology 45 (2004): 322. The lecture and criticisms of it offer a detailed bibliography that readers of this essay may wish to consult. A helpful anthropological reader on violence has been assembled and edited by Nancy Scheper-Hughes and Philippe Bour-gois (Violence in War and Peace [Malden, Mass.: Blackwell, 2004]) and a previous Tanner lecturer, Arthur Kleinman (“Experience and Its Moral Modes: Culture, Human Condi-tions, and Disorder,” in The Tanner Lectures on Human Values, Vol. 20, ed. Grethe B. Petersen [Salt Lake City: University of Utah Press, 1999], pp. 357–420), has devoted much of his ca-reer to exploring this topic. I am of course deeply indebted to these colleagues, and especially to Arthur and Joan Kleinman’s essay about the representation of suffering: Arthur Kleinman and Joan Kleinman, “The Appeal of Experience; the Dismay of Images: Cultural Appropria-tions of Suffering in Our Times,” in Social Suffering, ed. Arthur Kleinman, Veena Das, and Margaret M. Lock (Berkeley: University of California Press, 1997), pp. 1–24. See also Arthur Kleinman’s What Really Matters: Living a Moral Life Amidst Uncertainty and Danger (New York: Oxford University Press, 2006).

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societies built on deep inequality consist of wall-to-wall structural vio-lence, such an analysis leaves us at a loss for prescriptions and for ways to distinguish legitimate from illegitimate force.

I wish to do a better job of parsing the concept of structural vio-lence and cataloguing its many forms and also of promoting the human values that might lessen the toll taken by the violence and disease that are so tightly bound to poverty and social inequalities. I’d like to reflect on “strategically useful rhetorical tools,” too. These are tasks best ap-proached humbly, which is why so many questions will be raised in this lecture.

Part of my difficulty in making sense of violence stems, no doubt, from my experience working as a physician in settings of great poverty. The physician’s task is to serve the sick; medicine is more a vocation than an analytic discipline. But many doctors know a great deal about structural violence. Violence in one form or another is often enough the force that propels people into our clinics’ waiting areas; violence, which we have little difficulty in tracking to its sources, often interrupts or frustrates the job of identifying and remedying disease.

In this lecture, I will explore how structural violence is embodied as epidemic disease, violations of human rights, and genocide and reflect on the ways in which stories and images may be used to convey the damage done by structural violence. I will also explore the limitations, often sharp, of stories and images whenever we seek, to use Sontag’s words, “to moderate hell’s flames.” In raising questions about rights and values, and in contemplating images and stories revealing the structural violence that today claims millions of young lives, we revisit a number of the human values that Obert Tanner and others had in mind in estab-lishing this lecture series.

. An earlier book of mine, Pathologies of Power (2003), spurred a reviewer to ask sharp questions about my understanding of everyday violence:

Farmer never blames the poor for their poverty or the sick for their sickness. Clinical habits and the clinical-ethical tradition that has produced and is honored by those habits make any such blaming unlikely. Nonetheless, Farmer relates story after story in which misery has been made at home, made by neighbors, made by kin, made in cultures grown tolerant of cruelty. Thus is pulled a punch in this book that pulls no other, and thus is made a tension Farmer cannot himself gracefully resolve. (Robert H. Sprinkle, Review of

Pathologies of Power: Health, Human Rights, and the New War on the Poor by Paul Farmer, Journal of the American Medical Association 292 [2004]: 631–32)

I see the reviewer’s point, although I’m pretty sure he saw mine too. Blaming the victim is no hobby of mine, though removing all responsibility from victims who may also be per-petrators is hardly more charitable. In any case, my task here is to understand how various types of violence are linked and how they feed on each other.

. Sontag, Regarding the Pain of Others, p. 14.

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2. Epidemic Disease as Structural Violence

It was the philosopher Emmanuel Levinas who observed—and I’m just paraphrasing here—that ethics precedes epistemology. Our responsi-bility to each other precedes and grounds our duty to discover the truth. But where does ethics start? What makes a problem an ethical problem, as opposed to a merely technical or public-relations one?10 Can ethical thinking assume the willingness to act ethically? Do theory and rhetoric lead to action? Since these questions too have been argued for ages, I will start in what is, for me, an uncontentious arena: the medical and public health challenges before us right now.

The control of epidemic disease may seem an unlikely place to start in discussing human values, but the numbers are telling. Even if we consider only the big three infectious killers—AIDS, tuberculosis, and malaria­—we are faced with tens of millions of preventable deaths slated to occur during our lifetimes. A recent document from the United Nations­ suggests, for example, that more than 80 million Africans might die from AIDS alone by 2025.11 A similar toll will be taken, on that continent, by tuberculosis and malaria. Adding other infectious killers to the list, the butcher’s bill totals hundreds of millions of premature deaths over the next century.

But these numbers have lost their ability to shock or even move us. What are the human values in question when we hear, and fail to react to, the news that each day thousands die of these maladies unattended?

. Theologian Wayne Cavalier writes:

…because it is the primordial encounter with the other upon which our subjective being is predicated, we therefore owe our being to the other. Therefore, our moral indebtedness to the other is prior to our being, and it is the being as subject who “knows.” …Another way to put it: the encounter with the other gives rise to the subject; therefore, our indebt-edness to the other is at the very root of being. Epistemologically, this encounter and its consequences are the foundations of knowing. This radically changes the understanding of knowing from a process of absorbing the unknown into the subject to the fact of be-coming through the primordial encounter with the other. This changes the understand-ing of knowledge, understood from the prior ethical or moral indebtedness that brings the subject (usually understood as the knower) into being as a coming near, an encounter with extreme ethical consequences. (personal communication, July 22, 2005)

10. Elsewhere we have argued that contemporary medical ethics focuses on certain challenges (defining brain death, say, or the ethics of stem cell research) while ignoring oth-ers (lack of access to care for those living in poverty). See Paul Farmer and Nicole Gastineau Campos, “Rethinking Medical Ethics: A View from Below,” Developing World Bioethics 4 (2004): 17–41.

11. Joint United Nations Program on HIV/AIDS, AIDS in Africa: Three Scenarios to 2025 (Geneva: UNAIDS, 2005). One hopes and expects, of course, that the toll will be much lower. But the report outlines three plausible scenarios of the African HIV/AIDS epidemic over the next twenty years based on the current actions of the global and African communi-ties; all three scenarios—a “best-case situation,” a “middle-case” condition, and a “dooms-day scenario”—warn that “the worst…is still to come” (p. 20).

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Where, in the midst of all of these numbers, is the human face of suffer-ing? Can the reader discern the human faces in these reports? A failure of imagination is one of the greatest failures registered in contemplating the fate of the world’s poorest. Can photographs and personal narratives play a role, even as rhetorical tools, in promoting those human values that might lessen the magnitude of these disasters?

The strategy of countering a failure of imagination by having readers see the face of suffering is an old one in human rights struggles, as old at least as the eighteenth-century antislavery movement. Images, stories, and first-person testimony—rhetorical strategies or documentation or both?—remain the most relied-upon means of rendering these abstract struggles personal. Personalizing human suffering can help to make rights violations “real” to those unlikely to suffer them. Sometimes the challenge is to use narrative and imagery to shift the issue from “preserv-ing my rights” to “defending the rights of the other person.”

Sontag has written compellingly of the minefields one must traverse to use vivid images relating the pain and suffering of others. Writing of famine, genocide, and AIDS in Africa, she warns that the photographs “carry a double message. They show a suffering that is outrageous, un-just, and should be repaired. They confirm that this is the sort of thing which happens in that place. The ubiquity of those photographs, and those horrors, cannot help but nourish belief in the inevitability of trag-edy in the benighted or backward—that is, poor—parts of the world.” 12 The same critique has been leveled at the use of personal narratives.

In this lecture, as noted, the ethics of responding to the large-scale misery still rife in the modern world will precede the epistemological issues. And to prevent us from assuming that these tragedies are in-evitable, we turn to the experience of a young Haitian man who lay dying of AIDS and tuberculosis only a year or two ago. The story of his illness, and also of his failure to die, offers us a chance to consider the role human values play in confronting what is surely one of the greatest moral challenges of our times: addressing, through medicine and public health, inequalities of risk and outcome that have grown as steadily as has the gap between the richest and the poorest.13

12. Sontag, Regarding the Pain of Others, p. 71.

13. I have explored the growing gap between rich and poor and its relationship to epi-demic disease and violence in Infections and Inequalities and Pathologies of Power (Berkeley: University of California Press, 2003). A new book by Jeffrey Sachs, The End of Poverty (New York: Penguin, 2005), offers an economist’s view of this gap and its growth over the past three centuries; he also engages current debates among development economists. See also Jim Yong Kim, Joyce V. Millen, Alec Irwin, and John Gershman, eds., Dying for Growth: Global Inequality and the Health of the Poor (Monroe, Maine: Common Courage Press, 2000).

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Figure 1. Joseph shortly after his diagnosis of AIDS and disseminated tuber-culosis and prior to therapy (photo by David Walton).

On the afternoon of March 17, 2003, four men appeared at the pub-lic clinic in Lascahobas, a town in central Haiti; each carried one corner of a makeshift stretcher. On the stretcher lay a young man, eyes closed and seemingly unaware of the five-mile journey he had just taken on the shoulders of his neighbors. When they reached the clinic after the four-hour trip, the men placed their neighbor, Joseph, on an examina-tion table. The physician tried to interview him, but Joseph was already stuporous. His brother recounted the dying man’s story.

Joseph, twenty-six years old, had been sick for months. His illness had started with intermittent fevers, followed by a cough, weight loss, weakness, and diarrhea. His family, too poor, they thought, to take him to a hospital, brought Joseph to a traditional healer. Joseph would later explain: “My father sold nearly all that he had—our crops, our land, and

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our livestock—to pay the healer, but I kept getting worse. My family barely had enough to eat, but they sold everything to try to save me.”

Joseph was bed-bound two months after the onset of his symptoms. He became increasingly emaciated and soon lost all interest in food. As he later recalled, “My mother, who was caring for me, was taking care of skin and bones.”

Faced with what they saw as Joseph’s imminent death, his family purchased a coffin. Several days later a community health worker, em-ployed by Partners In Health, visited their hut. The health worker was trained to recognize the signs and symptoms of tuberculosis and HIV and immediately suspected that the barely responsive Joseph might have one or both of these diseases. Hearing that their son might have one last chance for survival, Joseph’s parents pleaded with their neighbors to help carry him to the clinic, since he was too sick to travel on a donkey and too poor to afford a ride in a vehicle.

At the clinic, Joseph was indeed diagnosed with advanced AIDS and disseminated tuberculosis. He was hospitalized and treated with both antiretrovirals and antituberculous medications. Like his family, how-ever, Joseph too had almost lost faith in the possibility of recovery. He remembers telling his physicians, early in the course of his treatment, “I’m dead already, and these medications can’t save me.” Contemplating a photograph taken by Dr. David Walton as Joseph began his treatment (figure 1), one can understand readily why he had given up hope.

Despite his doubts, Joseph dutifully took his medications each day, and he slowly began to improve. Several weeks later, he was able to walk. His fevers subsided, and his appetite returned. After discharge from the hospital, he received what is termed “directly observed therapy” for both AIDS and tuberculosis, visited each day by a neighbor serving as an accompagnateur.14 After several months of therapy, Joseph had gained more than thirty pounds (figure 2).

14. Accompagnateurs are almost always neighbors of patients—some of them patients themselves—who accept responsibility for supervising daily care and support for people suffering from AIDS or tuberculosis; they are trained by Partners In Health staff and are the cornerstone of our projects in Haiti, Peru, Boston, Rwanda, and elsewhere. This strategy for treating AIDS in what are now termed “resource-poor settings” is described in a num-ber of papers in the medical literature. See, for example, Paul Farmer, Fernet Léandre, Joia Mukherjee, et al., “Community-Based Approaches to HIV Treatment in Resource-Poor Settings,” Lancet 358 (2001): 404–9; Paul Farmer, Fernet Léandre, Joia Mukherjee, et al., “Community-Based Treatment of Advanced HIV Disease: Introducing DOT-HAART (Di-rectly Observed Therapy with Highly Active Antiretroviral Therapy),” Bulletin of the World Health Organization 79 (2001): 1145–51; and Heidi L. Behforouz, Paul E. Farmer, and Joia S. Mukherjee, “From Directly Observed Therapy to Accompagnateurs: Enhancing AIDS Treat-ment Outcomes in Haiti and in Boston,” Clinical Infectious Diseases 38 (2004): S429–36.

Figure 2. Joseph after six months of AIDS and tuberculosis therapy (photo by David Walton).

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A couple of years later, Joseph frequently speaks in front of large au-diences about his experience. “When I was sick,” he has said, “I couldn’t farm the land, I couldn’t get up to use the latrine; I couldn’t even walk. Now I can do any sort of work. I can walk to the clinic just like anyone else. I care as much about my medications as I do about myself. There may be other illnesses that can break you, but AIDS isn’t one of them. If you take these pills this disease doesn’t have to break you.”

What sort of human values might be necessary to save a young man’s life? Compassion, pity, mercy, solidarity, and empathy come immedi-ately to mind. But we also must have hope and imagination in order to make sure that proper medical care reaches the destitute sick. Naysayers still argue that it is simply not possible, or even wise, to deliver com-plex medical services in settings as poor as rural Haiti, where preven-tion should be the sole focus.15 Joseph’s story answers their misgivings, I feel, both in terms of fact (you can successfully treat advanced AIDS in this setting, and because good treatment serves to strengthen prevention programs) and in terms of value (it is worthwhile to try to do so). Cer-tainly Joseph and his family would agree, as would thousands of other Haitians who have benefited from these services.

But is the story over? Are the human values of compassion, pity,

15. These debates continue. See, to cite but one very recent example, the assertions by Harvard-trained economist Emily Oster, who seems to argue against the provision of antiretroviral therapy to patients such as Joseph, claiming that “antiretroviral treatment is around 100 times as expensive in preventing AIDS deaths as treating other sexually trans-mitted infections and around 25 times as expensive as education” (“Treating HIV Doesn’t Pay,” Forbes [July 25, 2005] [online]). But these inputs are changing rapidly with time: over the past few years, we have seen an over 90 percent decline in the cost of antiretrovirals, and there is little agreement about the efficacy of current prevention methods and of edu-cational campaigns among the very poor—the victims of structural violence. While noting that “[i]t may be that we have an objective other than maximizing the efficiency of dollars spent,” Oster nevertheless hews to static cost-effectiveness analyses, given these changes and debates: “In my work I have assumed that our goal in the face of the epidemic is to maximize life. In other words, to save the most years of life with the funding available.” But why is funding the constant in this life-or-death equation when funding and the cost of inputs are poorly studied and rapidly changing? Nor is her analysis epidemiologically sound: while citing the importance of treating sexually transmitted infections in order to prevent HIV transmission, she fails to link the critical importance of treating HIV infection (itself a sexu-ally transmitted infection in most parts of the world) in order to prevent HIV transmission. Our experience in rural Haiti has shown that demand for HIV screening, a cornerstone of prevention efforts, is low as long as effective care remains unavailable. For more on the debate, see Paul Farmer, “Prevention without Treatment Is Not Sustainable,” National AIDS Bulletin (Australia) 13 (2000): 6–9, 40; my exchange with Edward Green explores some of these complexities (Edward C. Green, “New Challenges to the AIDS Prevention Paradigm,” and Paul Farmer, “AIDS: A Biosocial Problem with Social Solutions,” Anthropology News 44 [2003]: 5–7), as do Helen Epstein’s recent essays in the New York Review of Books (“God and the Fight Against AIDS,” 52, no. 7 [April 28, 2005]: 47–51; and “The Lost Children of AIDS,” 52, no. 17 [November 3, 2005] 41–46).

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mercy, solidarity, and empathy all there is to it? How might the notion of rights reframe a question often put as a matter of charity or compas-sion? Conversely, what happens when other human values come to play in settings of epidemic disease? What happens when the human values in question are selfishness, greed, callousness, resignation, or just plain lack of imagination?

We know at least one answer to these questions. The director of Part-ners In Health and I were in Kenya in January 2004 and visited, along the shores of Lake Victoria, a number of communities seemingly bereft of young adults. We had not met any poor Kenyans receiving antiretroviral therapy—to date the only effective means of treating AIDS—and were anxious to learn more about efforts to introduce it to the Lake Victoria region. This is one of the epicenters of the AIDS pandemic, and surveys of young adults over the past two decades indicate rates of infection that range upward of 30 percent.16 Many of those people infected are dead or dying—even now, well over a decade after the introduction of effective antiretroviral therapy. In some areas, kinship networks have been nearly overwhelmed: in certain villages, children of those who die of AIDS are placed in orphanages almost as often as they are placed among their extended families. These days we hear a lot about the need for compas-sion for AIDS orphans, who number in the millions in Africa alone, but what arrangements might have prevented their orphaning?

The medications that saved Joseph’s life are commodities available throughout the global economy to those who can pay for them, and this is no less true in Kenya than in any other place. The people who have died without a single dose of effective therapy over the past decade are, almost without exception, people who lived and died in poverty. In order to make sure that poor people dying from AIDS stop dying, it will be necessary to move beyond what Sontag referred to as the “un-stable emotions” of compassion or pity,17 to more stable arrangements for all those afflicted with this and other treatable diseases. Translating compassion, pity, mercy, solidarity, or empathy into policy or rights is a difficult task.

But it is not an impossible task. How might we draw on certain ­human values to promote the notion of a right to health care and spark the imagination? A subsequent visit to Kenya, a year after the first one

16. Joint United Nations Program on HIV/AIDS, Epidemiological Fact Sheets on HIV/ AIDS and Sexually Transmitted Infections: Kenya, 2004 (Geneva: World Health Organization, 2004). Available at www.unaids.org/EN/Geographical+Area/by+country/kenya.asp.

17. Sontag, Regarding the Pain of Others, p. 101.

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and again in the company of the director of Partners In Health, re-minded us of the power of photographs. This time, we were traveling with the head of mission of a large charity that had recently received a significant amount of funding for AIDS relief. “Treatment is impor-tant,” he remarked after a day of home visits, adding that he’d recently seen a before-and-after-treatment photograph of a man who he assumed was Kenyan, since these images appeared in a Kenyan newspaper. “The difference between the two photographs was extraordinary,” he added. It was clear that he’d been moved and it seemed, too, that he was in a position to do something about it—to translate his reaction to the photograph, however “unstable,” into interventions designed to save the lives of those already sick. The photographs, it turns out, were the same ones you see above. Joseph’s images had made it across the world from Haiti to Kenya.

Do the destitute sick of Haiti or Kenya ask for our pity and compas-sion? Often they do. But can’t we offer something better? The human values required to save one person’s life, or to prevent children in a single family from losing their parents, surely include pity and compassion, and those sentiments are not to be scorned. Often it is possible to save a life, to save a family. But “scaling up” such efforts requires a modicum of stability and the cooperation of policymakers and funders, them-selves unlikely to suffer the indignities of structural violence. Partners In Health has worked for a long time in a small number of settings, seeking to make common cause with local partners to establish long-term medi-cal projects that strengthen, rather than weaken, public health. This means strengthening what is termed “the public sector” rather than, say, other nongovernmental organizations like ours or private clinics and hospitals. Nongovernmental organizations themselves can and should strengthen the faltering public sector.18 We proceed in this manner be-cause we’ve learned that the public sector, however weak in these places, is often the sole guarantor of the right of the poor to health care. Our own efforts take seriously the notion of the right to health care and also to freedom from hunger, homelessness, illiteracy, and other problems encountered in settings of great poverty. Others involved in nongov-ernmental organizations are also learning these lessons when they seek to inspire projects by social justice and a rights framework rather than

18. David A. Walton, Paul E. Farmer, Wesler Lambert, et al., “Integrated HIV Pre-vention and Care Strengthens Primary Health Care: Lessons from Rural Haiti,” Journal of Public Health Policy 25 (2004): 137–58.

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by what Rony Brauman of Médecins Sans Frontières has termed “the politics of pity.” 19

To move from pity and compassion for a sufferer like Joseph—a young man with a story, a face, and a name—to the values inherent in notions of human rights is a long leap. For many, especially those far removed from conditions such as those faced in rural Haiti or rural Kenya,­ the struggle for basic rights lacks immediacy. But sometimes we can entrap ourselves into becoming decent and humane people by advancing sound policies and laws. The road from unstable emotions to genuine entitlements—rights—is one we must travel if we are to transform humane values into meaningful and effective programs that will serve precisely those who need our empathy and solidarity most. In other words, we are not opposed to pity, but we’re anxious to press for policies that would protect vulnerable populations from structural vio-lence and advance the cause of social and economic rights.

Social and economic rights, which include the right to health care, have been termed the “neglected stepchildren” of the human rights movements and held up in opposition to the political and civil rights now embraced, at least on paper, by many of the world’s most powerful governments. So striking is this division within the rights movements that some have come to refer to social and economic rights as “the rights of the poor.” Certain African voices, at least, have argued that human rights language is not widely used on that continent because so little at-tention is paid, by the mainstream human rights organizations, to health care, clean water, primary education, and other basic entitlements. This means that little attention is paid to the voices of those who do not enjoy these rights.20 The language of political rights has become meaningless

19. See Rony Brauman, “L’Assistance Humanitaire Internationale,” in Dictionnaire de Philosophie Morale et Politique, ed. Monique Canto-Sperber (Paris: Presses Universitaires de France, 1996), pp. 96–101. Reflecting on his experience during the convoluted Cam-bodian refugee crisis of the late 1970s and early 1980s, Brauman notes that, for aid work-ers, “the choice was…not between a political position and a neutral position, but between two political positions: one active and the other by default” (Rony Brauman, “Refugee Camps, Population Transfers, and NGOs,” in Hard Choices: Moral Dilemmas in Humanitar-ian Intervention, ed. Jonathan Moore [Oxford: Rowman and Littlefield, 1998], pp. 177–94 at p. 181).

20. Chidi Anselm Odinkalu, in critiquing conventional human rights work in Africa, hazards a guess as to why so many human rights groups mirror the inequalities of our world: “Local human rights groups exist to please the international agencies that fund or support them. Local problems are only defined as potential pots of project cash, not as hu-man experiences to be resolved in just terms, thereby delegitimizing human rights language and robbing its ideas of popular appeal” (Chidi Anselm Odinkalu, “Why More Africans Don’t Use Human Rights Language,” Human Rights Dialogue: Human Rights for All? The Problem of the Human Rights Box 2 [2000]: 3–4, available at www.cceia.org/viewMedia.php/ prmTemplateID/8/prmID/602).

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to many people living in the worst imaginable poverty. Conversely, the language of economic rights is sometimes viewed as excessive, menacing, and irresponsible in the eyes of people living in the midst of plenty. This growing rift, I would argue, is the most pressing human rights problem of our times. As long as mainstream human rights organizations do not understand how poverty and inequality are also human rights viola-tions, rather than simply distracting background considerations, there is little hope of advancing the case for social and economic rights. Any doctor or public health specialist concerned with the health of the poor should agree, certainly. As long as certain fruits of modernity—in speak-ing of AIDS, certain diagnostic tests and medications—are considered commodities rather than rights, such sentiments as pity and compassion are not likely to be translated into meaningful changes for the millions who now need these resources to survive.

3. From Epidemics to Mass Killings: Arguing Genocide

Photographs, as we have seen, can provide a glimpse of the scandal of untreated disease and trigger the need to make sense of a problem such as AIDS in Africa; stories such as Joseph’s can “humanize” a colossal and impersonal catastrophe. But questions remain: when and where are such strategies effective? How does one measure efficacy?

Take the case of genocide, one of the defining human rights ques-tions of our times. The term is of recent provenance: it was coined by Raphael Lemkin in the mid-twentieth century to describe the policies of the Nazis. Although a fairly precise definition was proposed originally for the term, it is not often invoked. The feeling, among many, is that we know genocide when we see it. But do we?

Visuals have always been an important part of the evidence ad-vanced in arguing genocide. Again, we are leery of misusing images, because, as Sontag warns, “As one can become habituated to horror in real life, one can become habituated to the horror of certain im-ages.” 21 But we shouldn’t have to apologize for reporting what is really occurring. On February 23, 2005, Nicholas Kristof published an article about “The Secret Genocide Archive” in the New York Times, noting that “[p]hotos don’t normally appear with columns in this newspaper.” Kristof continues:

But it’s time for all of us to look squarely at the victims of our indif-ference. These are just four photos in a secret archive of thousands of

21. Sontag, Regarding the Pain of Others, p. 82.

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photos and reports that document the genocide underway in Darfur. The materials were gathered by African Union monitors, who are just about the only people able to travel widely in that part of Sudan.

…I’m sorry for inflicting these horrific photos on you. But the real obscenity isn’t in printing pictures of dead babies—it’s in our passivity, which allows these people to be slaughtered.

During past genocides against Armenians, Jews and Cambodi-ans, it was possible to claim that we didn’t fully know what was going on. This time, President Bush, Congress and the European Parlia-ment have already declared genocide to be underway. And we have the photos. This time we have no excuse.22

In his column, as in my telling of Joseph’s story and its echoes in Kenya, Kristof credits photographs with extraordinary evidentiary power— power that was not to be found, it would seem, in the equally graphic and far more detailed verbal testimony from Sudan in heavy circula-tion for more than a year. The power of the photograph, in his view, brings something new, something inarguable, to the equation. And yet, as Sontag has noted, photographs have long been used in this manner: “For a long time some people believed that if the horror could be made vivid enough, most people would finally take in the outrageousness, the insanity of war.” 23 Earlier she asks:

Who are the “we” at whom such shock-pictures are aimed? That “we” would include not just the sympathizers of a smallish nation or a stateless people fighting for its life, but—a far larger constitu-ency—those only nominally concerned about some nasty war taking place in another country. The photographs are a means of making “real” (or “more real”) matters that the privileged and the merely safe might prefer to ignore.24

Even during the course of the earlier genocides mentioned in Kristof’s piece, photographs of the slaughter existed; though widely circulated, they failed to stop the violence from continuing. There are omissions in Kristof’s inventory of recent genocides. One that didn’t make his list, at least not in the column cited, occurred in Rwanda, where I have

22. Nicholas Kristof, “The Secret Genocide Archive,” New York Times, February 23, 2005, p. A19. See also the continuation of these thoughts in his lucid essay “All Ears for Tom Cruise, All Eyes on Brad Pitt,” New York Times, July 26, 2005, p. A19.

23. Sontag, Regarding the Pain of Others, p. 14. 24. Ibid., p. 7.

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the great privilege of working as a physician. During the 1994 Rwan-dan genocide, some 800,000 people, perhaps more, were killed in 100 days. Survivors continue to grapple with the legacy of the killing, and not the least of their problems is how to discuss or represent what hap-pened during that year. For a long time, it was true that most people not from that region were simply unaware of the magnitude of the killing. A movie about the Rwandan genocide, which dramatizes the struggle of one middle-class Rwandan hôtelier at a time when close to a mil-lion died, is far more likely to result in widespread awareness of events already well chronicled and well photographed in scores of books. But such movies are not always honest about the history of such conflicts or why they happen. Do they, too, contribute to the belief that such trag-edies are inevitable “in the benighted or backward—that is, poor—parts of the world”? Do images and films and personal narratives erase the political economy of suffering in Rwanda and Haiti and elsewhere? The film industry does not have much of a taste for exposing the inner work-ings of structural violence.

What is most often left out of the story? An honest and unromantic look at that genocide would be one that focused on the region’s his-tory and its relation to the rest of the world. This is what Sontag means when she asks us to reflect “on how our privileges are located on the same map as their suffering.” Although much is made about the primi-tive agricultural implements used to do the killing, tiny Rwanda was in 1993 the continent’s third largest arms importer, behind Egypt and apartheid South Africa: some of the killing was in fact executed with modern weapons acquired from arms dealers operating out of Europe and elsewhere far from central Africa. And every honest exploration of the Rwandan genocide shows the key roles played by the government of France, which abetted the killers, and of the United Nations and the United States, which did little to stop them.25 A geographically broad web of violence linked events in Rwanda, and later Zaïre, with the com-plicity, rather than the detachment, of the industrial powers and of that mysterious entity, “the international community.”

The roots of what was termed, somewhat misleadingly, “ethnic frat-ricide” reach deep into the bloody soil of the colonial era, during which first German and then Belgian authorities laid down in great anthropo-metric detail the real and imagined differences between the Hutu and

25. Martin Meredith, The Fate of Africa: From the Hopes of Freedom to the Heart of De-spair—A History of 50 Years of Independence (New York: Public Affairs, 2005). See especially the damning assessment of France’s policies during the Rwandan genocide.

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Tutsi “races”—in quotation marks because the term is technically incor-rect and historically tendentious. Although these social distinctions are real and long predate European penetration of central Africa, colonial regimes ascribed to the region’s inhabitants immutable physical and social characteristics, buttressing and hardening hierarchies of human worth that had been less rigid in centuries prior to European contact.26 Layered upon this political and ideological foundation for inequality was the more recent field of growing social scarcity that served as an incubator for a bitter struggle for power—a slow-motion social catastro-phe that incited little interest among the powerful international actors who might have acted to avert what came to constitute the world’s larg-est mass killing in the latter half of the twentieth century.

Certain international actors, however, were far from passive bystand-ers. After the Rwandan military officer Juvénal Habyarimana seized power from fellow-Hutu Grégoire Kayibanda in 1973, the new dictator promised to ease growing tensions between the “Hutu Power Move-ment,” with which he and his predecessor were associated, and the Tutsi minority once favored by the Belgian colonial administration. Instead, the Habyarimana government was “relentless in the task of discrimina-tion [against] and scapegoating” of Tutsis,27 all the while siphoning off vast sums of government funds and foreign aid on the side. This did not deter those sending aid to an increasingly génocidaire government.

Reminded by Sontag of our obligation to locate our privilege on the same map as the suffering of our contemporaries, consider Franco-Rwandan relations. Journalist Philip Gourevitch underlines the close ties between the governments of Habyarimana and François Mitter-rand, ties that strengthened the Hutu-dominated military considerably. These ties were not focused exclusively on economic or development assistance:

A military agreement signed in 1975 between France and Rwanda ex-pressly forbade the involvement of French troops in Rwandan com-bat, combat training, or police operations. But President Mitterrand

26. To name but a few of the many books treating this subject, please see Philip Goure-vitch, We Wish to Inform You That Tomorrow We Will Be Killed with Our Families (New York: Farrar, Straus and Giroux, 1998); Gérard Prunier, The Rwanda Crisis: History of a Genocide (New York: Columbia University Press, 1995); René Lemarchand, “The Rwanda Genocide,” in Century of Genocides: Eyewitness Accounts and Critical Views, ed. S. Totten, W. S. Par-sons, and I. W. Charny (New York: Garland, 1997), pp. 408–32; and Mahmood Mamdani,

When Victims Become Killers: Colonialism, Nativism, and the Genocide in Rwanda (Princeton: Princeton University Press, 2001).

27. Fergal Keane, Season of Blood: A Rwandan Journey (New York: Penguin Books, 1997), p. 21.

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liked Habyarimana, and Mitterrand’s son Jean-Christophe, an arms dealer and sometime commissar of African affairs in the French Foreign Ministry, liked him too. (As military expenditures drained Rwanda’s treasury and the war dragged on, an illegal drug trade developed in Rwanda; army officers set up marijuana plantations, and Jean-Christophe Mitterrand is widely rumored to have profited from the traffic.) France funneled huge shipments of armaments to Rwanda—right through the killings in 1994—and throughout the early 1990s, French officers and troops served as Rwandan auxiliaries, directing everything from air traffic control and the interrogation of RPF [Rwandese Patriotic Front] prisoners to frontline combat.28

The role played by France was beyond the pale; the roles played by other powers were hardly glorious; United Nations efforts were, at best, wholly ineffectual. Others attempting to salve the suffering, including those working in nongovernmental organizations and human rights groups, were overwhelmed. In some instances, these organizations made things worse. It has been claimed that humanitarian aid to refugees of the Rwandan genocide served to prolong the conflict; some veteran hu-manitarian groups eventually conceded that they were doing more harm than good working in Rwandan refugee camps in Zaïre.29

As post-genocide Rwandans struggle to confront a burgeoning AIDS epidemic, itself accelerated by violence and poverty, the bloody residue of 1994 proves difficult to wipe away.30 It even clings to health

28. Gourevitch, We Wish To Inform You That Tomorrow We Will Be Killed with Our Families, p. 89.

29. Fiona Terry, then working with Médecins Sans Frontières in the Goma camp, writes searingly about mistakes made in allowing humanitarian aid to be diverted to the regrouped génocidaires and the former Rwandan military:

The history of the Rwandan refugee camps graphically illustrates the paradox of hu-manitarian action: it can contradict its fundamental purpose by prolonging the suffer-ing it intends to alleviate. Relief agencies rushed to avert immediate disaster among the refugees pouring into Tanzania and Zaïre, but inadvertently set the scene for the eventual disaster…. Former leaders manipulated the aid system to entrench their control over the refugees and diverted resources to finance their own activities. In short, humanitarian aid, intended for the victims, strengthened the power of the very people who had caused the tragedy. The consequences were devastating. (Fiona Terry, Condemned to Repeat: The Paradox of Humanitarian Action [Ithaca: Cornell University Press, 2002], pp. 1–2)

30. Even now, as I edit these proofs in rural Rwanda, I read or hear about the ongoing struggle for meaning, for a dominant narrative, that might “explain” what happened in 1994. Rwanda today is a safe and lawful nation, at least compared to the other countries in which I work and most of the countries that surround it. But the tensions persist. I sense them in the prisons, which are filled with génocidaires; in the sometimes uneasy relations between patients and doctors; in the impoverished villages we serve; and in the wild rumors and pre-dictions one hears in working in this traumatized nation. I read it in the news.

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Figure 3. Photograph taken within the chapel of Ntarama, March 2005, nearly eleven years after the Rwandan genocide claimed 800,000 lives (photo by Paul Farmer).

care providers concerned only to serve the sickest, regardless of their social or ethnic identities.

Some in Rwanda believe it is unwise to try and wipe away the residue of genocide. Better to display it. There are many genocide memorials in Rwanda; survivors have their reasons for leaving the evidence intact. I took this photograph (figure 3) inside a church in the village of Nta-rama, about an hour from the capital city of Kigali. Not far from the church, a banner promising “Never again” was draped over more bags

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Figure 4. “Never again” banner, Ntarama, Rwanda (photo by Paul Farmer).

of bones (figure 4). Since I do not work in that village, I am relying on others brave enough to tell their stories and on those who translated them from Kinyarwanda into English. Dancilla was born and raised in Ntarama; she lives there still and helps to tend the church, which is now a genocide memorial. Here is her story:

When the militia came in April 1994, I hid in the little church at Ntarama with my children. There were several thousand people crammed into the building—people who could not run into the hills. Our men had left us there as they thought we would be safe. In previous years when the government came to kill, they usually killed the men and left the women and children alone. We were very fright-ened but could not imagine what was going to happen.

The gendarmes arrived and broke some holes in the wall of the church—which you can still see today. They threw grenades into the crowds of people, then fired shots into the congregation. The noise of screaming and the mess was awful.

There were parts of bodies everywhere. I was covered by dying

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people, blood and filth. Some were still moving slowly, but most were dead. Then the doors were broken down so that the militia could come in and find anyone still alive—then they finished them off with machetes. I could hear the militia going about their “work” while my friends and neighbors groaned and breathed their last. I dared not move and thought I would suffocate under the bodies while I waited my turn to be butchered. There were so many people in there that they did not find me buried under the bodies.

After the militia left and everything was silent and dark, I crawled out from under the corpses. I learned later that my husband had been killed not far away from the church. My two children had been killed in the church also.

We survivors of Ntarama decided not to bury our loved ones. Why do we leave the bones of our families lying on the floor of the church? It would be easier and better for us to bury our loved ones and give them dignity. But that would also make it easy for everyone to forget. We do not want people to forget. Everyone must know what happened because of the extremists and because of the hatred. If people forget what happened when the UN left us, they will not learn. It might then happen again—maybe to somebody else. We owe it to our families to make the world remember. That is why we wait here like this. It makes me happy that people can come here and learn what happened, or that people far away can know about this place. For the sake of the future we must keep this memory alive.31

31. Dancilla’s story is told on the website of the Rwanda Fund (www.rwandafund.org/ sections/survivors/dancill.htm), an organization dedicated to preserving the memory of the genocide and promoting educational and economic opportunities for Rwandan children. I thank Beth Collins for taking me to Ntarama and for finding Dancilla’s testimony. I am of course deeply grateful to Dancilla for leading us through the memorial.

Jean Hatzfeld has made a valuable contribution by interviewing, in prison, about a dozen low-level génocidaires and a couple of more notorious criminals, all of them Hutu. The entire book (and his previous one, which focuses on genocide survivors) merits careful reading, but here I’d just like to translate the comments of one of the killers who participated in the massacre in Ntarama. What were the killers thinking when they violated the church in order to kill everyone inside?

Thursday, when we entered the church in Ntarama, the people were lying quietly in the shadows. The wounded were visible between the pews; the still unwounded scattered under the pews; the dead in the aisles at the foot of the altar.

We were the ones making all the noise. They awaited death quietly in the church’s tran-quillity. For us, it was no longer important that we were in the house of God. We yelled, we joked, we gave orders, we insulted. We went person to person, checking everyone’s face, to finish them off carefully. If we had any doubt regarding whether or not someone was dead or dying, we dragged the body outside to inspect it in the light of day.

Myself, I’d been baptized sincerely as a Catholic, but I preferred not to pray in any

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Dancilla’s experience is far from unusual, except that, left for dead, she survived to recount her story. Psychological horrors aside, it was not dif-ficult to meet her or to document her story. Once again, it wasn’t a fail-ure of intelligence, to use the jargon of our times, that allowed genocide to happen. Her account also belies the claim that only machetes were used to kill 800,000 people in 100 days. The grenades and guns Dancilla mentions were not made in Rwanda, and following the paper trail will likely reveal that even the machetes were imported—some with the help of loans from aid agencies deeply implicated, some have argued, in set-ting the stage for what was to follow.32

What are the human values that might have stopped or at least slowed these mass killings? How might we have “moderated the flames” of the hell that was Rwanda in 1994? Indignation is not enough, we know; nor is the goodwill of people like you or me. Nor do “bearing witness” and documentation suffice; these were abundant. Even United Nations of-ficials ostensibly in a position to do something to save lives in Rwanda found themselves hobbled by forces much larger than they. Take the experience of General Roméo Dallaire, who led the UN peacekeeping force in Rwanda and survived the genocide, although some of his troops did not. The impotence of his office is evident in his memoir, Shake Hands with the Devil. Dallaire watched as Rwanda went up in hell’s flames and hundreds of thousands of people were murdered at close range, but he found his every move hampered by bureaucratic processes and worse. Dallaire couldn’t get the extra troops he needed; nor could he get materials, armored vehicles, even water. The French government, as noted, helped to arm and train the génocidaire government and stymied peacekeeping in ways that will eventually come to light: long-overdue investigations of French complicity in the genocide are now under way in both France and Rwanda. The U.S. administration, still smarting from the killing of American soldiers in Somalia, pressed for a reduction

traditional manner during these killings. There was nothing to be asked of God as regards these filthy acts. Nonetheless, to be able to sleep certain nights, I couldn’t help kneeling in the dark to lessen, with timid apologies, my darkest fears. (Jean Hatzfeld, Une Saison de Machettes [Paris: Éditions du Seuil, 2003], p. 160)

This is my translation, but Hatzfeld’s book has recently been translated into English: ­Machete Season: The Killers in Rwanda Speak, trans. Linda Coverdale (New York: Farrar, Straus and Giroux, 2005).

32. Peter Uvin’s book Aiding Violence (Bloomfield, Conn.: Kumarian Press, 1998), which explores humanitarian and development aid in Rwanda just prior to the genocide, remains a classic and cautionary tale for all of us seeking to “manage inequality” through the conventional aid apparatus.

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in the size of the peacekeeping force in Rwanda and refused to commit any troops to the effort. African lives, it seems, just weren’t worth it. A passage from Dallaire’s memoir merits highlighting:

As to the value of the 800,000 lives in the balance books of Wash-ington, during those last weeks we received a shocking call from an American staffer, whose name I have long forgotten. He was engaged in some sort of planning exercise and wanted to know how many Rwandans had died, how many were refugees, and how many were internally-displaced. He told me that his estimates indicated that it would take the deaths of 85,000 Rwandans to justify the risking of the life of one American soldier. It was macabre, to say the least.33

A cost-effectiveness analysis, a price-tag, applied to a peacekeeping effort in Africa. Macabre indeed. And how terrible it often felt, we learned, to have survived when so many others died.34 Dallaire does not mistake himself for a vulnerable Rwandan. He does not claim to be the victim. But he did not stand aside and let things take their course: he tried to act on his realization and, by his own account, failed.35

Dallaire has often said that what happened in Rwanda was made possible by the world’s racism. The world’s indifference to the fate of a large subset of humanity continues to haunt him. He wasn’t able to stop the genocide, but he couldn’t walk away from it. He wanted to make sure the lesson would not be forgotten and spoke out about the genocide after he was relieved of his duties in Rwanda. This included testifying at tribunals to judge the guilty. For his pains, General Dallaire was given a stern dressing-down by his superiors in the Canadian armed forces:

Either Dallaire had to abandon the “Rwanda business” and stop tes-tifying at the tribunal and publicly faulting the international com-munity for not doing more, or he would have to leave his beloved

33. Roméo Dallaire, Shake Hands with the Devil: The Failure of Humanity in Rwanda

(New York: Carroll and Graf, 2004), pp. 322–23.

34. Sontag’s comments remind us, perhaps, of how Dallaire felt about surviving the Rwandan genocide: “We can’t imagine how dreadful, how terrifying war is; and how normal it becomes. Can’t understand, can’t imagine. That’s what every soldier, and every journalist and aid worker and independent observer who has put in time under fire, and had the luck to elude the death that struck down others nearby, stubbornly feels. And they are right” (Regarding the Pain of Others, pp. 125–26).

35. Dallaire, as Samantha Power has noted, “was of course not a Tutsi and thus not a member of the group that had been marked for extermination in Rwanda…. But…Dallaire warned of the horrors that lay ahead and described the massacres as they were happening” (preface to Dallaire, Shake Hands with the Devil, p. ix).

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military. For Dallaire, only one answer was possible: “I told them I would never give up on Rwanda…I was the force commander and I would complete my duty, testifying and doing whatever it takes to bring these guys to justice.” In April 2000 Dallaire was forced out of the Canadian armed services and given a medical discharge. Dal-laire had always said, “The day I take off my uniform will be the day that I will also respond to my soul.” But since becoming a civilian he has realized that his soul is not readily retrievable. “My soul is in Rwanda,” he says. “It has never, ever come back, and I’m not sure it ever will.” 36

The list of human values that would be relevant to averting genocide, if we agree that values might avert genocide, grows long even in consid-ering a few paragraphs from Dallaire’s book or from the many others written about the Rwandan genocide. These values are, by and large, the same ones that might avert deaths from untreated infectious disease. But once again we must ask if values alone can prevent death on a mas-sive scale.

A good lecturer shouldn’t repeat himself, at least not too much. But the forms of violence, the epidemics killing the poor, and human rights abuses of all sorts make up a catalogue of repetitions. The most massive and lethal upheavals, especially genocides, are inevitably followed by pledges “never again” to tolerate genocide. “Never again”—again and again. As one journalist has recently noted in reporting from Darfur:

There are mass graves and there is mass rape. Men and boys are taken away to be killed.

Then the government denies the scale of the violence. It keeps journalists out, blocks aid workers.

Many more die from hunger and disease. The world expresses concern but does too little, invariably too late.

A handful of foreign troops are allowed to deploy, but they are too few and their mandate is too restrictive to allow them to inter-vene and fight the killers.

Yes, we have been here before.

Bosnia, Rwanda and those are only the ones that have happened in our own time.

I gave up having any faith in the phrase “never again” after Rwanda.

36. Ibid., p. xvi.

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I now add another verbal formulation to the list of redundant phrases.

It is the sentence “We must learn the lessons.”

It is of course invariably the precursor to the words “never again.”

“We must learn the lessons of the Holocaust, or of Cambodia, or of Bosnia, or of Rwanda…and make sure that things like this”…and you know how this sentence ends…“things like this never happen again.” 37

Staring at the “never again” banner in Ntarama, it occurred to me that although Joseph’s and other photographs had a certain persuasive power in promoting AIDS treatment in Haiti and in Africa, there is little rea-son to believe that even more graphic images might move those with power to avert genocide in Rwanda or Sudan. The Rwandan genocide was among the world’s most reported and photographed of mass kill-ings. But abundant documentation, visual or otherwise, had virtually no role in halting that genocide. It was in fact a Rwandan rebel force—a military action, performed by people wielding guns, not cameras—that halted the killing. This is one of those unpleasant facts that gall all those who hope that knowledge and documentation will sway the powerful and alter the course of history.

4. Human Suffering and the Politics of Representation

This is the world in which we live, the world in which we consider the meaning of human values. A world in which one is obliged to apologize for displeasing images, even in the print news media. A world in which certain images are dismissed as gratuitous or even pornographic, while the policies and arms sales that feed the killing depicted in those images are ignored, as are most of the political and economic mechanisms by which structural violence is perpetuated. A world in which we cannot, granted, be sure such images will do anything to move the viewer be-yond the unstable emotions of pity or revulsion to meaningful action.

Contemplating Darfur leads me back to Haiti. The UN undersecre-tary-general for peacekeeping, Jean-Marie Guehenno, recently traveled from Darfur to Haiti, noting that many Haitians endure conditions

37. Fergal Keane, “Why ‘Never Again’ Keeps Happening,” BBC News, July 2, 2005. Avail-able at http://news.bbc.co.uk/go/pr/fr/-/1/hi/programmes/from_our_own_correspondent/ 4641773.stm.

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worse than those suffered by internally displaced Sudanese.38 The sit-uation is certainly dire some two centuries after Haiti, once France’s most lucrative colony, became an independent republic. There should have been much to celebrate upon Haiti’s bicentennial: the country is in many senses the birthplace of values that we celebrate as modern, as it was the first nation in the world to outlaw slavery—the source of vast European profits and of the slave revolt that transformed the colony into Latin America’s first sovereign nation. Haiti’s second constitution, promulgated in 1805, declared that all citizens, regardless of skin color, were to be known as nègres; prohibited foreign ownership of land; and reclaimed as the country’s name the term used by the island’s indigenous people. Haiti meant “high country” to the original inhabitants, mil-lions of Arawak who had almost all died out a century after Christopher Columbus established Europe’s first New World settlement in 1492. The constitution declared “the Black Republic” a safe haven not only for escaped slaves from other colonies and from its only sovereign neighbor, the United States, but also for indigenous people lucky enough to sur-vive their first contact with the Europeans.39

Haiti in 1804 had few friends. The small country, in cinders after a decade of war waged successfully against Europe’s greatest powers, was surrounded by the slave economies of Jamaica, Cuba, and the south-ern United States. Its leaders tried to make some friends by helping Simón Bolívar and others to cast off colonial rule in the New World. One of the conditions of this assistance—imagine Haiti offering foreign aid to Bolívar!—was that slavery be abolished in the nascent republics of South America. And Haitian troops, former slaves, marched east to abolish slavery in what is now the Dominican Republic.

Haiti’s first century as an independent nation was a difficult one. Bolívar did not keep his promise and in fact tried to block Haiti’s formal participation in international affairs. The Dominican Republic, once independent, became and remains a country in which racism—and

38. Peter Heinlein, “UN Peacekeeping Chief: Haiti Worse Than Darfur,” Voice of Amer-ica, June 28, 2005. Available at http://www.voanews.com/english/2005-06-28-voa63.cfm. In the wake of mounting evidence that UN forces may have killed up to two dozen civilians, Guehenno admitted that the peacekeeping forces in Haiti are not sufficiently trained and equipped to curb the mounting political violence (Andrew Buncombe, “UN Admits Haiti Force Is Not Up to the Job It Faces,” Independent [UK], July 30, 2005, p. 31).

39. Haiti’s early constitutions were based to some extent on France’s brief experiment with liberté, fraternité, and egalité; but with Napoléon Bonaparte’s re-establishment of slav-ery in France’s other New World holdings, Haiti could claim rightly enough to constitute a better example of these Enlightenment ideals than its former colonizers.

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dislike­ of all things Haitian—is tolerated or condoned.40 Throughout the nineteenth century, Haiti remained isolated by trade embargoes and the world’s refusal to recognize the sovereignty of a country born of a slave revolt. The twentieth century was no easier: gunboat diplomacy was followed, in 1915, by U.S. military occupation. Franklin Delano Roosevelt ended the occupation in 1934, but decades of military and paramilitary dictatorships ensued. Haiti’s first democratic elections were not held until 1990.

What transpired over the next fourteen years is much disputed, but it needn’t be: Haiti’s brief experience with democracy is readily docu-mented if one searches long and hard enough for the facts. Honest and careful historians will no doubt hash this out in scholarly texts to come, should the fate of democracy in Haiti ever prove worthy of impartial judgment. What we know is this: that in spite of a spectacular coup at-tempt (by Duvaliériste and paramilitary forces) between the elections and the installation of the elected president, the inauguration of the liberation theologian Jean-Bertrand Aristide took place on February 7, 1991. Father Aristide’s government’s policies reflected liberation theol-ogy: ambitious programs to promote adult literacy, public health, and primary education were quickly launched, as were campaigns to raise the minimum wage, opposed vigorously by Haitian and U.S. factory owners, and to promote land reform, opposed by those with large and often fallow landholdings. Tensions were high, and in September the Aristide government was overthrown by yet another military coup, this one anything but bloodless. Yet another military dictatorship began.

Earlier I promised to focus on proximity and connections, to con-tinue following Sontag’s exhortation that we look hard at the ways in which our privileges are located on the same map as others’ suffering— “in ways we might prefer not to imagine.” This strategy is especially revealing, and painful, to Americans seeking the truth about Haiti. It is an incontrovertible fact that the modern Haitian military was supported by the foreign government that had created it during the U.S. occupa-tion of Haiti. (Some will note a certain symmetry, here, with the recent history of Rwanda. But in the case of Haiti, as elsewhere in Latin Amer-

40. There are no monuments to the Haitian Revolution in the Dominican Republic; in fact, the past century has been marked by a number of anti-Haitian pogroms. In 2003, it was clear enough that the Dominicans were turning a blind eye to former Haitian soldiers using that country as a base from which to conduct raids against Haitian government of-ficials, and the past two years have seen a marked resurgence of anti-Haitian violence in the Dominican Republic.

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ica, it was the U.S. government and not France that gave assistance and training to the army.) The degree to which the first Bush administration, claims to the contrary aside, secretly abetted the 1991 coup is much de-bated. But there is no doubt that a CIA asset in Haiti formed and led the vicious paramilitary group named FRAPH, credited with many of the murders committed during the years following the coup.41

By 1992, Haiti was like a burning building from which the only exit was over the border shared with the Dominican Republic or across the sea. Tens of thousands of refugees headed for the United States; the United Nations condemned the U.S. policy of forcibly returning Hai-tian refugees and declared post-coup Haiti “a human rights nightmare.” Hundreds of thousands were internal refugees, fleeing the pro-Aristide urban slums targeted by the military and paramilitary forces to rural refuge or to the neighboring republic, famously hostile to Haitians.

Endless negotiations, orchestrated by the UN and the Organization of American States, seemed to lead nowhere—the military dictators re-fused to budge—until there was a change of administration in Wash-ington, D.C. Bill Clinton had promised, during his campaign, to stop the forced repatriation of Haitian refugees and to restore constitutional rule to Haiti. President Clinton did not find, in his own country, much support for his proposed sanctuary of Haitian asylum seekers. The flood of unwelcome refugees to Florida played a role in forcing his administra-tion to stanch the flow of refugees by stopping military and paramilitary terror in Haiti.

Given the topic of this lecture, I’d like to turn again to the role of photographs in shaping the policy that eventually led to the re-establish-ment of constitutional rule in Haiti. The insider’s tale has recently been published by John Shattuck, a self-described “human rights hawk.” A ­human rights lawyer and former vice-chairman of Amnesty Interna-tional who had taught at Harvard, Shattuck joined the Clinton admin-istration in June 1993, as Assistant Secretary of State for Democracy, ­Human Rights, and Labor. “Soon after taking office,” Shattuck recalls, “the administration of Bill Clinton was confronted by the post–Cold War forces of disintegration. Within eighteen months, disaster had struck in

41. FRAPH’s brutal methods have been well documented by watchdog groups since its inception in 1993; see, for example, Human Rights Watch’s annual reports at http://hrw. org/doc?t=americas&c=haiti. Regarding the ties between FRAPH’s leadership and the CIA, see, for example, Alan Nairn, “Behind Haiti’s Paramilitaries,” Nation, October 24, 1994, p. 458, and “The Eagle Is Landing,” Nation, October 3, 1994, p. 346; this information was later reported in Newsweek, Time magazine, and the major dailies.

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Somalia, Rwanda, Haiti, Bosnia, and China. Human rights conflicts were erupting or escalating in virtually every part of the world.” 42

Conflagrations in Rwanda and Haiti came to occupy much of Shat-tuck’s time, but since Haiti is a close neighbor with strong ties to the United States, it is unsurprising that the crisis in “our backyard,” then generating huge numbers of refugees, loomed larger than the catastro-phe evolving in Rwanda (the government of France, malicious enough in Haiti, focused more on its own “sphere of influence”). Shattuck’s ac-count of how the United States came to intervene in Haiti is interesting for many reasons, but one of them is surely that we get a clearer view of how decisions about such grave matters are made. Clinton himself favored using military force, if necessary, to restore democracy in Haiti: “the strategy had many opponents inside the Beltway, but the President knew it was time to reach over their heads and take it to the public.” 43 How did Clinton come to feel so strongly about this matter when Wash-ington’s power elite saw little reason to waste time and energy, or to jeop-ardize American lives, on account of Haiti? How did his government manage to promote what was, in the United States, a fairly unpopular policy? Shattuck reports that he called the U.S. ambassador in Haiti, asking him for photographs of the atrocities taking place there. In the end, he reports, it was Amnesty International that proved more helpful on this score: there was, as noted above, plenty of documentation about what was going on in Haiti. Shattuck’s job was to brief the President on September 14, 1994, since Clinton himself planned to present his pro-posal to the U.S. public the very next day. Shattuck continues:

Early in the afternoon of September 14, I spread my photos of the disfigured faces and bodies of Haitians who had recently been at-tacked by the FRAPH on a coffee table in the Oval Office. Examin-ing them closely one at a time, the President swore quietly, “Those bastards,” and vowed that Haiti’s reign of terror would be brought to an end. The statistics I summarized for the President spoke for them-selves—more than three thousand killed since the 1991 coup against Aristide, including nearly a thousand in the first eight months of 1994; mass graves found by human rights monitors; an estimated 300,000, or 5% of the population, driven into flight or hiding; and

42. John Shattuck, Freedom on Fire: Human Rights Wars and America’s Response (Cam-bridge, Mass.: Harvard University Press, 2003), p. 13.

43. Ibid, p. 106.

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thousands of cases of mutilation, rape, and beating of Aristide sup-porters by the regime’s network of gangs. As I talked, the President stared at the hacked and mutilated bodies of men, women, and chil-dren trapped on an island ruled by thugs.44

And so the deed was done: constitutional rule was restored to Haiti in 1994 with U.S. military force, a policy buttressed with photographic evi-dence of the butchery that prevailed during the previous three years. Not a single American life was lost from hostile fire during the course of the operation. But there are many ways to undermine popular democracy, and what followed was a decade of “structural adjustment” programs forced on Haiti by the same international community that had declared that Haitian democracy should be restored.45 Aristide served out what little was left of his term and became, in 1996, the first Haitian president ever to hand over power to another elected president—on precisely the day such a transfer of power was slated to occur.

Aristide was re-elected in 2000, the first year he could run again, according to the Haitian constitution. Another Bush administration was installed at almost the same time as Aristide returned to office. The strength of the Haitian leader’s mandate—Aristide won more than 90 percent of the votes cast—did not mean that he’d have any economic strength, since the bulk of his political support came from the poor rather than Haiti’s wealthy elite, notoriously reluctant to pay taxes. And it is clear that the “new” U.S. policy gurus on Haiti were precisely those who’d disparaged the left-leaning Haitian populist during the first Bush administration. What ensued is, again, readily documented: a virtual

44. Ibid, pp. 106–7. It’s worth citing the rest of Shattuck’s account of that day:

Later that afternoon I worked with Taylor Branch and the White House speechwriting team to hone Clinton’s television message. The speech should apply equally to American values and American self-interest, pointing out that in a country near the coast of Florida human rights and refugee crises were also threats to U.S. security. Clinton’s response should be measured, firm, and deliberate. “The nations of the world have tried every pos-sible way to restore Haiti’s democratic government peacefully,” the President would say. “The dictators have rejected every possible solution. The terror, the desperation, and the instability will not end until they leave.” Then would come the ultimatum: “The message of the United States is clear. Your time is up. Leave now or we will force you from power.” On September 15, 1994, the President delivered this message in a televised address to the nation. (p. 107)

45. The contours of these economic policies, and their impact on the health of the Haitian poor, are explored further in Paul Farmer and Didi Bertrand, “Hypocrisies of De-velopment and the Health of the Haitian Poor,” in Dying for Growth: Global Inequality and the Health of the Poor, ed. Jim Yong Kim, Joyce V. Millen, Alec Irwin, and John Gershman (Monroe, Maine: Common Courage Press, 2000), pp. 65–89.

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embargo on aid or credits to the cash-poor Aristide government. The impact of such policies in a country as poor as Haiti is readily imagined and readily documented.46 Haiti in 2004 was the most impoverished nation in the hemisphere and one of the poorest in the world. There was simply no way to ease poverty in Haiti without access to credits or by recovering the billions that had been extorted from Haiti in the preceding centuries. Every credible economist examining the case came to precisely this conclusion, that the aid embargo was strangling Haiti. Shortly after its bicentennial celebration, marked solemnly by post-apartheid South Africa but by precious few other nations, Haiti endured its thirty-third coup d’état and lost tens of thousands to violence, floods, and epidemic disease.

Questions remain. In many ways Haiti was the first state in the west-ern hemisphere to put into practice the modern notion of rights: it was the first nation to proclaim universal equality among races, and the first to offer a sanctuary to oppressed refugees. Then why is Haiti so burdened with violence and degradation and disease? Why does every tropical storm lead to more loss of life and devastation in Haiti than in neighbor-ing countries? Why is Haiti the hemisphere’s most HIV-affected nation? Why was this the island on which polio, declared eradicated from the western hemisphere in 1989, recurred? Why is Haiti, the source of much of eighteenth-century France’s wealth, now one of the poorest and most volatile countries on the face of the earth? Why is political stability so elusive, and violence and rights violations so endemic? Why is it so dif-ficult, even when the tools of the trade are made available, to practice good medicine and public health in the western hemisphere’s neediest nation?

To answer each of these questions, it is less useful to examine the culture of the “natives” than to seek to understand Haiti’s history and its place in the modern world economy. I have tried to do that elsewhere and stand by my conclusion that Haiti’s poor majority is by no means to blame for the mess it finds itself in, today or at any point in the last two hundred years.47

Not all the news from Haiti is bad. We know from our own ex-perience that it is possible to deliver high-quality health care in rural

46. We attempted to do so in reviewing the effects, over the years, of aid embargoes on Haiti. See, for example, Paul Farmer, Mary Catherine Smith Fawzi, and Patrice Nevil, “Unjust Embargo of Aid for Haiti,” Lancet 361 (2003): 420–23. The impact of such a review in the medical literature is probably negligible.

47. See Paul Farmer, The Uses of Haiti, 3rd ed. (Monroe, Maine: Common Courage Press, 2006).

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central Haiti, where there are neither paved roads nor electricity. Haiti can also claim to have led the charge against AIDS in the poor world, having launched some of its first integrated prevention-and-care pro-grams; Joseph’s experience is not rare in central Haiti. These efforts have not gone unnoticed. As the neighboring republic, with a gross national product several times that of Haiti, retreated from its goal of offering all poor Dominicans access to modern AIDS care,48 some Haitian public health leaders pressed on. A new funding mechanism, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, allowed Haiti to ramp up long-standing efforts to prevent new infections and to improve care for the sick. Even as some poor nations seemed ready to concede defeat in the struggle against what had become the world’s leading infectious cause of adult death, Haiti could point to real victories. Laurie Garrett, writing in the New York Times in July 2004, noted that “a new Global Fund report shows that of the 25 projects supported by the fund for more than a year, 80 percent have already either achieved or even sur-passed their five-year goals. As chaotic as it is, Haiti surpassed its 2006 targets after only a year of Global Fund support.” 49 Another article, even more detailed and based on reporting from central Haiti, was titled “Rural Haitians Are Vanguard in AIDS Battle.” 50 People like Joseph, and those who cared for him, were leading a movement not only to make AIDS prevention and care a right but also to revitalize, often with assistance from the Global Fund, Haiti’s shattered public health sector. It seemed to be working.

It was optimism born of just such experiences—and a belief in the suasive power of photographs and narratives—that led friends and co-workers from Partners In Health to put together a photographic exhibit called “Structural Violence: A View from Below.” Most of the pictures were taken in Latin America. Many of these photographs were of my own patients, and all of them were taken by my colleagues, some of whom chose the photographs and the title of the exhibit; others did the work of hanging them in a public space in a Harvard University build-ing and designing and mailing an invitation.

The response to the exhibit was largely positive, judging from

48. Eugene Schiff, “Deadly Bureaucracy: Dominican Republic Retreats from ‘3 x 5’ Com-mitments, Lowers ARV Access Goals,” Agua Buena Human Rights Association (Costa Rica), September 13, 2004, available at http://www.aguabuena.org/ingles/articules/dominican burocracy.html.

49. Laurie Garrett, “Bragging in Bangkok,” New York Times, July 16, 2004, p. A21.

50. Celia Dugger, “Rural Haitians Are Vanguard in AIDS Battle,” New York Times, November 30, 2004, p. A1.

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­comments in the guest book. One photograph, however, offended a visitor, who wrote in the guest book “not appropriate at all.” This ver-dict was underlined twice and also telephoned to the building admin-istration as a formal complaint. To avoid giving offense to this visitor and—presumably—others similarly affected, the photography show’s organizers took the picture down.

The offending photo (figure 5) is one in a series of informal portraits of a Haitian woman struggling to survive breast cancer and poverty. It was taken by her physician, once again Dr. David Walton, during the course of a home visit. Like most women living in dire poverty, Lorièze, who is from the same town as Joseph, had been diagnosed tardily. In her case, the tumor had already consumed much of her breast. She had a mastectomy in the Partners In Health hospital in central Haiti. After-ward, another physician carried some of the tissue to Boston in order to find out if Lorièze might benefit from chemotherapy. She would and she did. These interventions were delivered with technical competence and hope and a great deal of love—some of the human values central to good medicine.

Surgery and chemotherapy—services hard to come by in rural Haiti and available to the rural poor, to my knowledge, only in our hospital —gave Lorièze a second lease on life. The photo was taken with the subject’s blessing, as were the other photographs in the display. Indeed, many of our patients, including Joseph, have asked that their pictures be taken; many have asked for copies of these images. What about this photograph, I wonder, prompted such an extreme reaction? It can’t be just the depiction of a breast (a spectacle to which the general public is no doubt as inured as I, a medical professional). Is it the suggestion of disease, surgery, pain, and other things we prefer not to think about? Or is it the deeper history that the photograph expresses, if we only know how to decipher it?

Lorièze is doing much better, according to her doctors. But nothing will change the fact that she wandered around Haiti’s towns for more than a year, looking for someone to diagnose and treat her illness, and found nobody. There is no right to health care for the Haitian poor. Breast cancer is awful anywhere; so are other malignancies, AIDS, drug-resistant tuberculosis, and a host of other diseases that afflict the poor disproportionately. But once afflicted, the victims of structural violence are in a very different situation from others diagnosed with the same

Figure 5. Lorièze after surgery and chemotherapy for breast cancer, Lascaho-bas, Haiti (photo by David Walton).

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illnesses. The destitute sick, if they are ever diagnosed, are unlikely to receive proper therapy for their afflictions. Again, there is no right to health care.

Surely the right to health care, like other social and economic rights, is important. It grows more so as modern medicine delivers increasingly effective therapies: just over a decade ago, there was no treatment for AIDS. But people living with AIDS face many other problems. Those we serve in Haiti, Rwanda, Peru, Boston, and Siberia have told us in no uncertain terms that food, housing, jobs, and shelter—freedom from want—are the rights they care most about. Yet these are not the rights discussed often in the affluent world, where civil and political rights have long dominated the agenda, when human rights are discussed at all.

Have we tried hard enough to push for the rights of the poor? Surely the answer to this question is a resounding no. As noted, there’s a good deal of ambivalence, within human rights circles, about most social and economic rights. Is the right to health care somehow different? We’ve discovered that some people who don’t think much about the right to food or housing or employment are sympathetic to the right to health care, perhaps because almost anyone, rich or poor, can imagine what it would be like to be sick and without medical care. When health services are for sale and the destitute are not, by definition, capable buyers, what happens to them? In Haiti, only an hour and a half from Miami, civil and political rights are important—nothing could be more clear from recent news as scores die each week, fighting to restore constitutional democracy there51—but the daily struggle is mostly for survival. And although Haitians do not enjoy the right to health care, they do, in my experience, have systematic and comprehensive notions about such rights.

An expanding notion of human rights (and I’m not just talking about the theory) is now emerging, but it is coming from the poor rather than from the mainstream human rights groups that receive their funding

51. The current crisis in Haiti was precipitated by the overthrow of constitutional rule in February 2004. For more on those events, see Paul Farmer, “Who Removed Aristide?” London Review of Books 26 (2004): 28–31; and Peter Hallward, “Option Zero in Haiti,” New Left Review 27 (2004): 23–47. A recent report from the University of Miami School of Law details the agonies of the Haitian pro-democracy movement, especially that part of it that is committed to respecting the rights of the poor majority. Again, photographs, often grue-some, lend great power to the report—as if such images are more difficult to gainsay than are other forms of documentation. See Thomas M. Griffin, Haiti: Human Rights Investigation, November 11–21, 2004 (Miami: University of Miami School of Law, 2004).

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from the powerful.52 Many of the patients we serve are articulate in as-serting tout moun se moun—every one is human. The currency of this proverb is striking in Haiti, the very land in which human rights have so long had little practical reality. The subtext of tout moun se moun is usually that poor people deserve access to food, education, housing, and medical services. We hear this sort of commentary almost every day in our clinics in central Haiti.

The commodification of medical care is one of the biggest human rights issues facing the “modern” world today.53 Why use quotation marks around “modern”? Scare quotes are typically a craven ploy, but I use them here because the woman whose picture offended the viewer, though undeniably our contemporary, lives in a low-medieval hut, with a dirt floor and a thatch roof. There is no running water. As in Kenya and even Rwanda, modern health care is available, for a price, in the private clinics of the city, but she received it for free in a rural squatter settlement only after a long time spent knocking fruitlessly on the doors

52. Although there are scores of human rights organizations in the United States, one in particular, the National Economic and Social Rights Initiative (www.nesri.org), focuses on social and economic rights.

53. Linking medical care to the ability to pay has had devastating consequences for the majority in a country as poor as Haiti. But commodification of care is also a signifi-cant problem in certain wealthier industrialized countries. The most obvious example is the United States, where access to health care is increasingly shaped by market forces rather than by need, and where an ever-growing number of people may go without care because they lack the means to purchase it. For more on the commodification of medical care, especially in the United States, see the review by Barbara Rylko-Bauer and Paul Farmer, “Managed Care or Managed Inequality?: A Call for Critiques of Market-Based Medicine,” Medical Anthropology Quarterly 16 (2002): 476–502.

The Kaiser Commission on Medicaid and the Uninsured reports that more than 45 million Americans went without health coverage during 2004 (Health Insurance Cov-erage in America: 2004 Data Update, Washington, D.C., 2005; available at www.kff.org/ uninsured/7415.cfm). As many more are irregularly insured or underinsured. In a 2002 publication titled Care without Coverage: Too Little, Too Late, the Institute of Medicine at-tempted to sift through studies of what it means to have no reliable insurance. One study, for example, followed 4,700 Americans for at least thirteen years and found that death rates were 18.4 percent for those without insurance and 9.6 percent for the insured. Another study found more than 18,000 “excess deaths” among uninsured Americans, compared with those with health insurance (Washington, D.C.: National Academy Press, 2002). Mary Sue Coleman, president of the Iowa Health System and University of Iowa, who co-chaired the IOM committee, put it this way: “Because we don’t see many people dying in the streets in this country, we assume that the uninsured manage to get the care they need, but the evidence refutes that assumption…. If you lack health insurance coverage you’re going to have a poor health status, a greater chance of dying early and your quality of life is not going to be as good because of poor health care” (www4.nationalacademies.org/news.nsf/ isbn/0309083435?OpenDocument). If this is the case within the borders of the richest, most powerful nation in human history, you can imagine what the situation is like where people are indeed “dying in the streets.”

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of those modern clinics as a patient without money. Until she wandered into our clinic and hospital, she was effectively locked out of the modern world, with all its shiny laboratories and amazing medications.

The experience of a Haitian woman dying of breast cancer, her death delayed by desperate but effective measures, offers more lessons about structural violence, itself an effect of the dizzying social inequalities spanned by our lives and work. All those involved in her care agree that it is “not at all appropriate” that only a tiny fraction of the afflicted has access to proper medical care. We join our voices to those of our patients, who, not having visas to leave their countries, cannot be “empowered” to come and tell their stories in Boston or New York or Geneva or Salt Lake City.

Spanning the worlds of rich and poor is what human rights organiza-tions, aid organizations, and universities do; so do rich-world govern-ments. The images and narratives shown so far, and also the histories of Haiti and Rwanda, all remind us of proximity rather than distance. Wealthy and powerful institutions have certain obligations to the rest of the world. What are these obligations? Do wealthy and powerful peo-ple who do not support the noxious policies of their own governments have obligations to the victims? No good answers to these questions are forthcoming­ as long as those who, through privilege, can span these worlds but do not understand the struggles of people facing the poverty and disease that luckier people are spared.

Are photographs of awful suffering “not at all appropriate,” are they cause for apology when printed in the New York Times because they break down boundaries erected in order to keep misery far away? Are disturbing images of ongoing suffering “inappropriate” because they undermine facile and fashionable notions of “empowerment”—facile because the concept lacks any meaning if not linked to social and eco-nomic rights, including the right to health? None of this is to say that representation of the sufferings of others is not fraught with danger. Sontag examines the photographic record of black victims of lynch-ing in early-twentieth-century America and asks: “What is the point of exhibiting these pictures? To awaken indignation? To make us feel ‘bad’; that is, to appall and sadden? To help us mourn? Is looking at such pictures really necessary, given that these horrors lie in a past remote enough to be beyond punishment?” 54 But recall that the images and stories shown here, during this lecture, are those of our contemporaries,

54. Sontag, Regarding the Pain of Others, pp. 91–92.

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caught up in the same web of privilege and suffering as we are. Are these photographs and stories disturbing because they do not depict those from another era but rather those who share our time and (in the era of globalization) space—people who really are destitute and sick and frightened, and would be so whether or not someone took their pictures or told their stories?

The list of questions, worrying this thin membrane separating the fortunate from the unfortunate, goes on and on.

The political and moral culture of affluent universities (or main-stream human rights or aid organizations) seems, at times, not to share a planet with rural Haiti or with Rwanda. Major campus and institutional struggles have often concerned issues of representation. It is inherently controversial: I can easily agree with the proposition that the photogra-pher (even the physician-photographer) stands, through luck, privilege, education, and social standing, in an unequal relationship to the person photographed. As a graduate student in anthropology, I heard frequent discussion of who has the right to take a photograph and display it. Of course academics and commentators such as Sontag have written tomes on photography, and anthropologists have a strange obsession with rep-resentation (in both artistic and political senses). But the photographs in the Partners In Health exhibit and in this lecture were not displayed to exploit the suffering of others but to bring people whose lives are dif-ferent and far less difficult—that is, people like us—into a human rights movement to which the fortunate would have a great deal to offer. The goal of these photographs and stories is to inspire, not offend; to alter the fates of people like Joseph, Dancilla, and Lorièze—and those who have not survived. When linked to other forms of analysis (in the case of the photographic exhibit, to books and articles and lectures—the traditional products of a university) these photographs do not simply move people to pity or indignation, useful though those feelings may be. The photographs are meant to take us beyond superficial analyses of long-standing ills. The point is to testify to deep questions of history and political economy and to offer us all a chance to think about health care as a right. Dismissing such images as “not at all appropriate” is an excellent way of stopping that conversation and of undermining our understanding of why, for example, the likeliest outcome for the poor in Haiti, Kenya, or Rwanda would be death without even a diagnosis, much less therapy.

An apology from a New York Times columnist serves, as no doubt

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intended, to draw our attention to an ongoing catastrophe. His apology is “strategically useful as a rhetorical tool,” to echo Loïc Wacquant. Our eyes are drawn to these images. But we are also often called to avert our gaze from suffering. An anonymous visitor’s expression of anger cannot readily be glossed as “political correctness”—the blanket claim, often heard from conservative corners, that such images have no place in public spaces. These sentiments bespeak, I believe, a very different malady: a desire to avert our gaze from things that should in all propri-ety make us uncomfortable. Of course we should also try to approach this peremptory comment—“not at all appropriate”—as generously as we can. Personal experience is immediate and truthful as far as it goes; an announcement of discomfort can never be dismissed. But one might devoutly wish that such images would at least inspire pity and compas-sion, regardless of the viewers’ personal experiences. Better still if they were to inspire more stable emotions, such as empathy, and to result in solidarity—in some ways surely the most noble of human sentiments.

In reflecting on human values, wouldn’t it be wonderful if the com-ment was meant to tell us that it is “not at all appropriate” that some die of treatable diseases while others are spared that risk? Or that photo-graphs from Darfur or Rwanda should spark, among the millions who see them in print or broadcast or posted on the Internet, the desire to stand with the victims, to stop the killing? Because without such sentiments, we will not forge a movement to reverse the trends now registered, and we will live in a world divided, in an increasingly violent fashion, between haves and have-nots.

Such sentiments, as noted, will not suffice. But the promise of so-cial movements based on solidarity and empathy remains alive, however tenuously. For “never again” to inspire something other than cynicism, nothing less than a movement will do.

5. Human Values and Social Movements

Why do we need a movement to promote the “rights of the poor,” and how might such a movement prevent events like those registered in Haiti, Rwanda, and Sudan? The relationship of poverty to human rights is no mystery to those who live in poverty, as we learned in rural Haiti; nor is the relationship of poverty to violence, including extreme violence and genocide. I’ve learned a great deal about rights by listening to people in rural Haiti. Every year for the past decade our Haitian patients and co-workers have sponsored a conference on health and human rights. In

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Figure 6. Joseph speaking in front of his before-and-after photographs, Tenth International Seminar on Health and Social Justice, Cange, Haiti (photo by Joia Mukherjee).

2004, as in previous years, the huge crowd included patients with AIDS who were actually receiving proper therapy for the disease at no cost to them. This was the only way they could receive such care, as a public good rather than as a commodity. Many more in the audience were dying of untreated or inappropriately treated AIDS, but these individu-als—not yet patients, to their dismay—were from elsewhere in Haiti and were there to fight for their right to health care.

One of the speakers that year was none other than Joseph (figure 6). Since the time of his miraculous resuscitation, he has been involved in AIDS-prevention efforts; he has become, as had many of those gathered together for the conference, an eloquent spokesman on behalf of people living with AIDS and in poverty. On that day, as he spoke, he projected photographs of himself before and after treatment—the very same pho-tographs I’ve shown you, the same photographs that had made their way to Africa and beyond. As elsewhere, the photographs drew applause. In the hands of Joseph, the images were a witness not only to the miracles of modern medicine but also to the power of first-person testimony. He spoke with passion and with a certain humor about his own near-death experience and about his hopes for the future. “One of the things I’d like

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to do is to learn how to read,” he said. “It’s ridiculous that even today adults who are poor do not know how to read.”

A number of questions were raised, largely for the sake of discussion. More likely, they were “rhetorical tools,” aimed perhaps at members of the audience who were health professionals or policy makers, a distinct minority in rural Haiti. Should people dying of AIDS be spared only if they can pay for the antiretroviral therapies that will save them? Should people living in poverty have a right to primary education, to learn how to read? Should they have the right to food and shelter? Should poor women have the right to benefit from early detection of breast cancer? And when it is detected, should they have the right to chemotherapy? The people who showed up to discuss health care in a church in rural Haiti knew that the answers were self-evident: yes, of course. But such ques-tions would strike some of my colleagues in both the international health and human rights “communities” as absurd. This is because most exter-nal determinants of disease—poverty, inequalities of all sorts—are still considered off-topic by many human rights experts and policy makers.

The view of many of my academic colleagues seems to be that good scholarship and activism don’t mix. The view of many of my human rights colleagues seems to be that social and economic rights—those violated in settings of poverty and disease—are “pie in the sky.” We’re having a hard enough time, I’m scolded by friends in large human rights organizations, getting civil and political rights respected. The view of many in both sectors seemed to be that, if such rights were to be pro-moted, then the victims themselves should be “empowered” to start their own social movements. And yet it is not possible to argue that those gathered in central Haiti needed to form a movement to promote human rights; they already had. The missing movement is among the privileged; it would be one based on solidarity and empathy, rather than some sort of shared experience.

The people living with HIV who spoke in the conference were aware of the long list of reasons marshaled by university-trained experts to show that we cannot provide “cost-effective” care for AIDS, for exam-ple, in the world’s poorest communities. The list of reasons is not often overtly racist or sexist and does not include anything approaching frank contempt. The reasons (or excuses) for not addressing these complex diseases are framed more subtly. We’ve heard, for example, from a senior U.S. Treasury Department official (who wisely declined to be named) that Africans lack a “concept of time” and so cannot adhere to complex

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therapeutic regimens. Even a “lack of wristwatches” has been advanced as a reason not to treat.55 The Haitian AIDS sufferers had heard these stories and retorted, as they had done in previous conferences on health and human rights, “We may be poor, but we’re not stupid.” 56 They were familiar with the thousand other excuses we dish up to explain genocide, human rights abuses, the persistence of poverty, the growth of inequal-ity, and the futility of trying to fight diseases as complex as breast cancer and AIDS in places as poor as Haiti.

Relativism is a part of the problem. Why is it impolitic in the groves of academe to argue that dying of never-treated AIDS in a dirt-floored hut in Africa is worse than dying of AIDS in a comfortable hospice in Boston after having failed a decade of therapy? I’ve been present for both kinds of death—at matside and at bedside. No death of a young per-son can reasonably be called good. But I’ve seen almost nothing worse than dying of AIDS and poverty, incontinent and dirty and hungry and thirsty and in pain. I’ve experienced almost nothing worse than hearing that a Rwandan woman raped during the genocide, and now dying of AIDS, cannot be treated because she cannot afford the various labora-tory tests and medications required to treat her disease. I’ve seen almost nothing worse than a poor Haitian woman dying of breast cancer with-out any care at all, leading to what’s called, aptly enough, a fungating mass that completely replaces normal breast tissue and then consumes flesh and bones—an excruciatingly painful death uneased, in settings of poverty, by palliative care or even wound care. That is the fate that struc-tural violence reserves for those living with both poverty and disease.

So it is with human rights violations as conventionally defined: the victims are disproportionately to be found among those living in poverty. Ask those who’ve invested their lives, their medical careers, in

55. Joseph Kahn, “Rich Nations Consider Fund of Billions to Fight AIDS,” New York Times, April 28, 2001, p. 10. Andrew Natsios, administrator of the U.S. Agency for Inter-national Development, who spent a decade in aid work in Africa, said that many Africans “don’t know what Western time is. You have to take these [AIDS] drugs a certain number of hours each day, or they don’t work. Many people in Africa have never seen a clock or a watch their entire lives. And if you say, one o’clock in the afternoon, they do not know what you are talking about. They know morning, they know noon, they know evening, they know the darkness at night. I’m sorry to be saying these things, but a lot of people like Jeffrey Sachs advocating these things have never worked in health care in rural areas in Africa or even in the cities” (John Donnelly, “Prevention Urged in AIDS Fight,” Boston Globe, June 7, 2001, p. A8).

56. A statement from a previous conference, in which a group of people living with HIV pressed for the right to health care (including antiretroviral therapy), is summarized and quoted at length in the closing chapter of my book Pathologies of Power (pp. 216–20).

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providing medical services to some of the most desperately endangered people in the world. Dr. Gino Strada, a successful Italian transplant surgeon, decided that he would try to help civilians—most of them children and the great majority of them poor—injured by land mines and other man-made pathogens. After a decade of this grueling work, in Rwanda and Pakistan and in many other places, Dr. Strada concludes that he was wrong not to have done all his homework on what might as well be termed structural violence:

We thought that war was an old, primitive instrument, a cancer that mankind did not know how to eradicate; on this point we were mistaken. Tragically, we—and not only we—had failed to see that war, rather than being a burdensome inheritance from the past, was becoming a fearful prospect for our future and for generations to come. In the operating theatre we saw the devastation produced in human bodies by bombs and mines, by projectiles and rockets. Yet we did not succeed in grasping the effects of other weapons, “uncon-ventional” ones: finance and international loans, trade agreements, the “structural adjustments” imposed on the policies of many poor countries, the new arms races in richer countries.57

Whether or not we see these horrible deaths, whether or not we avert our gaze, they are happening. Those who must face structural violence every day encounter precious little in the way of support for the right to food, water, housing, or medical care. Even within the human rights movement, where civil and political rights are privileged, there is far too little support for social and economic rights. Maybe magical thinking persuades us that when political rights are granted, economic rights will follow. But that step-by-step attitude has not always been the ortho-doxy: there are historical precedents for enshrining social and economic rights in official human rights declarations. One need only read the Uni-versal Declaration of Human Rights: articles 25 and 27 seem to speak directly to the issue and are infused with the human values advanced in this lecture:

Article 25: (1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, includ-

57. Gino Strada, Green Parrots: A War Surgeon’s Diary (Milan: Charta, 2005), p. 132.

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ing 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. (2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.

Article 27: (1) Everyone has the right freely to participate in the cul-tural life of the community, to enjoy the arts and to share in scientific advancement and its benefits.

And these articles are actionable, at least on a small scale and almost surely on a much larger one, if we find the rhetorical tools necessary to bring the privileged on board as we build a movement to promote the rights of the poor. Indeed, following this mandate led Partners In Health from rural Haiti to shantytowns in Peru to prisons in Siberia and on to the former killing fields in Rwanda. But for these basic rights to be extended to all those who need them—a prescription that would prevent, in my view, much of the violence discussed here and much of the terrorism about which we read—we will need a movement based in nations like the United States, wealthy nations that now control the fates of billions who live far from their shores.

The tasks at hand in each of these places are overwhelming. A daunt-ing to-do list serves as a reminder that only a social movement involving millions, most of us living far from these difficult settings, could allow us to change the course of history. But history also provides us examples of just how powerful broad-based social movements can be. Some have argued that the first great human rights struggle, to abolish the slave trade and slavery itself, got its beginnings when the Englishman Thomas Clarkson, born in the late eighteenth century, submitted an essay in Latin just prior to graduating from Cambridge University. It was an es-say about slavery, an enterprise in which his home country was deeply invested but of which he had no personal experience. In his memoirs, which are drawn upon in an important new book by Adam Hochschild, Clarkson recalls his own inner debate as he rode back to London after graduation. He stopped by the side of the road, unable to ride on as his thoughts about slavery consumed him. “Are these things true?” he asked himself. “The answer followed as instantaneously. ‘They are.’” His initial

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conclusion: “‘Then surely some person should interfere.’ Only gradu-ally, it seems, did it dawn on him that he was that person.” 58

Clarkson asked a very “unpostmodern” question. Yes, or no, are these things true? And he came up with a very unpostmodern answer. Yes. Surely someone should interfere with this man-made abomination, slavery?

And interfere he did. Clarkson and his friends and consociates, some of them former slaves, spent decades building up an antislavery move-ment, performing the hard chores of what we now call “community organizing.” He and a dozen or so others, many of them Quakers and several of them influential in England, began a vast campaign. They went from town to town, traveling tens of thousands of miles on horseback, to collect signatures for petitions, to call town meetings, and to research the slave trade, gathering expert witnesses and amassing testimony. Pho-tography did not yet exist, but those spearheading the movement relied heavily on stories and images, including the infamous floor plans of a slaving ship, as rhetorical tools and as documentation. Personal nar-ratives were offered by, or written about, former slaves. Although the antislavery documents compiled for the lower house of Parliament were praised for their “dispassionate” tone, there was no doubt that the sugar boycotts and giant parchment petitions were fueled by indignation. These rhetorical tools proved effective.

If the antislavery movement sounds modern, this is because it was. Imagine what these people were up against. They lived in a monarchy; very few British subjects could vote. England derived huge profits from the triangular trade; this was in part why it ruled the high seas. Sugar, rum, tobacco, and other tropical produce had become everyday staples in Europe and the emerging “new world” on which we stand today— “necessities,” if you asked the people lucky enough to enjoy them—and yet the movement was ultimately a successful one within a few decades of Clarkson’s epiphany.

The story of the antislavery movement does not teach us, as blurb writers like to say, that one person can change the world. That may be true, but the lesson to be gathered from the abolitionists is that broad social movements can have great force in the world. The human rights movements of today have too often been co-opted by powerful states,

58. Adam Hochschild, Bury the Chains: Prophets and Rebels in the Fight to Free an Em-pire’s Slaves (New York: Houghton Mifflin, 2005), p. 90.

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the leaders of which have their own reasons for claiming to respect hu-man rights. But powerful governments do not form movements. Their citizenry might.

6. Violence and Values: Rehabilitating Compassion,

Pity, Solidarity, Empathy?

It’s a fact that abominable events and processes—from torture to slav-ery to genocide to unassuaged suffering from epidemic disease—are documented and recognized as such even as they are occurring. But recognition is not enough. Sontag says it best: “What does it mean to protest suffering, as distinct from acknowledging it?” 59 Even protest is not enough. If ever we are to say “never again” and mean it, we will need more than resolutions and more than photographs or stories or museums or Hollywood-style movies. We need another modern move-ment, a globalized movement that will use whatever stories and images it can to promote respect for human rights, especially the rights of the poor. For such a movement to come about, we need to rehabilitate a series of sentiments long out of fashion in academic and policy circles: indignation on behalf not of oneself but of the less fortunate; solidarity; empathy; and even pity, compassion, mercy, and remorse. For such a movement to come about, we will need rhetorical tools based on fact, not ideologically motivated fiction.

Sparking such emotions with testimony and photographs is one thing; linking them effectively, enduringly, to the broader project of promoting basic rights, including social and economic rights, is quite another. Stories and images need to be linked to the historically deeper and geographically wider analyses that can allow the listener or the ob-server to understand the ways in which AIDS, a new disease, is rooted in the historically defined conditions that promote its spread and deny its treatment; the ways in which genocide, like slavery before it, is a fun-damentally “transnational” event; the reasons why breast cancer is in-evitably fatal for most affected women who live in poverty; the meaning of rights in an interconnected world riven by poverty and inequality. In short, serious social ills require in-depth analyses. We are living, it is true, at a time when movies and rock concerts are more likely to garner wide-spread attention than are scholarly books or lectures or long essays. And yet comparable troves of attention are required to reconfigure existing

59. Sontag, Regarding the Pain of Others, p. 40.

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arrangements if we are to slow the steady movement of resources from poor to rich—transfers that have always been associated, as in Rwanda and Haiti, with violence and epidemic disease.

I titled this Tanner Lecture “never again” because the human values I prize are those that would make such horrors—dying unattended from treatable disease, facing genocide—things of the past. The lecture was meant to be ambitious and humble. The lecture is ambitious because I promised to link poverty and inequality to epidemic disease and geno-cide, and to argue that a broad-based movement founded on the values of solidarity and empathy could attack twenty-first-century poverty and inequality. In so doing, we would make a signal contribution to prevent-ing violence, since it is almost always rooted in precisely those social arrangements I’ve termed structural violence. This is as true in Haiti as it is in Rwanda and Sudan; it is true elsewhere, too. The lecture is humble because it raises many questions and I don’t know the answers. Chastened by Loïc Wacquant and others, I suspect that the concept of structural violence is “strategically useful as a rhetorical tool,” but I lack confidence in its theoretical value. It is often better simply to say so, as the Polish poet Wysława Szymborska has observed: “I just keep on not knowing, and I cling to that like a redemptive handrail.” 60

Szymborska’s poem “Tortures” packs violence and its increasing in-terconnection with history into just a few lines:

Nothing has changed.

The body still trembles as it trembled before Rome was founded and after,

in the twentieth century before and after Christ.

Tortures are just what they were, only the earth has shrunk and whatever goes on sounds as if it’s just a room away.61

We live in a world in which violence and epidemic disease, only a room away, are linked tightly to those who are spared. A world bound tightly together and yet held firmly apart. A world in which violence—the re-

60. Wysława Szymborska, “Some People Like Poetry,” in Poems New and Collected 1957–1997, trans. Stanisław Barańczak and Clare Cavanagh (New York: Harcourt Brace and Company, 1998), p. 227.

61. Wysława Szymborska, View with a Grain of Sand: Selected Poems, trans. Stanisław Barańczak and Clare Cavanagh (New York: Harcourt Brace and Company, 1995), pp. 151– 52.

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flection, surely, of certain values—seems to be ineradicable. A world in which terror is met with more terror. We live in a nation and world in which there exists great and alarming confusion about the term “moral values.”

I’ve tried to dissipate some of that confusion by making use here of stories and images while linking them to a deeper analysis that is not visible in either image or personal narrative. That is, I’ve tried to use the media that create an illusion of immediacy, to remind us of the very real closeness among people and places that our society keeps as far apart as it can. Our collective inattention is periodically broken by stories and arresting images. In such lucid and engaged moments, we can seek to understand the violence of our world system, which it is suddenly once again fashionable to call an “empire.” 62 To claim, after all we have seen and heard, that such violence will never again occur is not only to ignore the lessons of history but to be willfully blind to structural violence: “No one after a certain age has the right to this kind of innocence, of superfi-ciality, to this degree of ignorance, or amnesia.”

Understanding the nexus of violence and disease is a discourag-ing enough endeavor. Whether or not this or other similarly sorrowful

62. Antonio Negri and Michael Hardt, Empire (Cambridge, Mass.: Harvard University Press, 2000). It is impossible to close an essay about violence and suffering without reference to Iraq. David Rieff, who has been one of the few reliable observers of the human rights de-bates mentioned in this lecture, has recently reviewed two books about Iraq, Squandered Vic-tory by Larry Diamond and Losing Iraq by David L. Phillips. In both books, we see the myth of “never again” raised as a reason to reflect on what some of us would term the misadven-tures of our imperial ambitions, even though neither author has any real gripe with the idea of invading a sovereign nation. Diamond asserts that “if we learn from our mistakes, our next engagement to help rebuild a collapsed state might have a more successful outcome” (David Rieff, “No Exit Strategy,” Nation, August 1, 2005, p. 33); Phillips seeks to lay out the U.S. administration’s “mistakes in Iraq so that it does not repeat them elsewhere” (ibid., p. 34). Rieff’s conclusion is resonant with the arguments made in this essay:

Both books illustrate and exemplify the extraordinary consensus about the duty to inter-vene that has arisen over the course of the post-cold war world. We have not yet begun to pay the price for this—not because we do it ineptly but rather because it rarely seems possible except on the far fringes of the political right and left, what with the “historical compromise” between the Bush Administration and the human rights movement over humanitarian intervention, if not over torture, rendition, the Patriot Act and myriad other issues, to have a serious conversation about whether the United States has any busi-ness trying to create democracy by force of arms. Instead, the consensus not just of two writers and activists but of the great and the good from the Kennedy School of Govern-ment, to 1600 Pennsylvania Avenue, to the thirty-eighth floor of the UN, to 10 Downing Street seems to be that we—whether the “we” in question proves to be the United States, the UN or that mythical entity, the international community—must learn to do this sort of thing better, more effectively, perhaps more humanely. (Rieff, “No Exit Strategy,” p. 36)

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exercises­ prove useful to those seeking to improve the health and well-being of the world’s poor—whether or not we can say “never again” with any conviction—will depend on our collective courage to examine and understand the roots of modern violence and the violation of a broad array of rights, including social and economic rights. To argue that such an undertaking leads to nothing “actionable” is to raise a white flag and to surrender our chance to lessen the heavy toll of both violence and disease.

DMU Timestamp: June 06, 2022 19:12