Last year I got together with Dr. Paul Farmer for a talk. In part two of our conversation, I ask Farmer about the limits of “applied” social science; the reasons for his apparent optimism; and whether, after all these years, he at all considers himself an anthropologist.

In terms of attending to the practical needs of the poor, there are few who doubt that Paul Farmer practices what he preaches. In 1987, while still a young anthropology student at Harvard, he co-founded Partners in Health with his fellow student Jim Yong Kim (today president of the World Bank) among others. Since his ethnographic fieldwork in Haiti in the late 1980s, a whole host of “Paul Farmers” seem to have sprung up: Doctor, Harvard professor, author, infectious-disease specialist, UN special envoi to Haiti, globetrotting Robin Hood.

But when I ask whether he also still considers himself an anthropologist, after all his travels outside the confines of the discipline, he looks surprised.

PF: Yes, I do. I mean you don’t have to, but I do, and I always will. I didn’t know that being an anthropologist meant that you had to be, as we say in the US, a card carrying anthropologist.

[…] Here is how I feel: It doesn’t matter if my ideas are not that influential in academic circles. If someone doesn’t like a paper I wrote in an anthropology journal, that’s OK. You know, I’ll try some other time, or maybe try a new idea, right? I am not inside a single institution; I am not inside a single hospital at Harvard, or in Haiti. I admire people who can do that – enclose themselves – but I can’t.

And I am not offended when people don’t like a paper I wrote. I used to be when I was a graduate student, but I was cured of that by being a physician and working in places like Haiti.

The uses of the ivory tower

SW: I get a sense from what you are saying here that social science has been too concerned these last few decades with deconstruction, or destructive critique.

PF: Well, I feel that academia can contribute very constructively through critique and understanding, and partly does so already. For example, a lot of people in NGOs, aid and development work are unable to do social analysis. And that is hurtful to them; because they are not aware of what they are doing can hurt beneficiaries, or doesn’t help them. So I think there is a big role for the weaving together practical policy and social analysis. It has to be an accurate analysis though. Let’s say you write a book about an institution and you don’t do ethnographic work – you wouldn’t do that as an anthropologist.

But I think it comes down to a division of labor. And if there is enough division of labor, people who do critical academic work can perform a valuable service to people living in poverty. But the answer to the question of “what is to be done” is not always to write a new book.

The people living in poverty are my core constituency. And I have never, in 30 years of engagement, had a patient ask me to write another book. But I write them anyway, so that I can think more clearly. I can’t think clearly without reading a lot of other people’s work and writing. Some people I am told can do that, and I believe it, but not me. But no-one’s ever said to me, “Dr. Paul, we really wish you would stop seeing us as patients and building hospitals, and work more on a book about social theory.” That doesn’t mean I wouldn’t do it, if I had more time. I think I would actually enjoy writing a whole book about a concept like structural violence. But I can’t do that, because I don’t have enough time. But if other people do that, and enjoy it, and I’m cheering them on.

SW: There seems to be a core of optimism in your writing, which seems rare to find among scholars working in deprived locations. Where does that come from?

PF: “Pessimism of the intellect is appropriate but optimism of the spirit is necessary.” I don’t remember who coined that phrase, but I’ve always liked it.

But part of my optimism comes from working collectively. A lot of academics don’t get to do that. They work by themselves. If you put your energy in a collective movement, say, labor rights in Norway, or racial equality in the 1960s, or fighting against unjust wars – and if you stick with it long enough, and you believe that the arc of history is fundamentally bending towards justice – then it doesn’t seem to be optimism to the point of not understanding realistic and sound analysis.

So, there are several sources of optimism. Getting out there with others is important. That’s what doctors do, not so much academics.

SW: Getting out of the ivory tower.

PF: Yes, and think of all the ways in which we have ivory towers! Gated communities, monasteries, those are good places to think and write. And at times it is useful to lock yourself in, to think that your ideas are the most important thing on earth, to cut off the rest the world. It is by creating a bubble that you can get deep thinking and writing done.

But I’ve seen a lot of people become in love with their own ideas at the end of that process. And then spend their careers repeating their ideas, and feeling in the end that their ideas are products not to be molded, and shaped and improved but to be maintained. And I don’t that recommend that to my students because it’s a trap. And luckily, ethnographers can get out of that by just going out to a new place.

Paul Farmer was never an orthodox anthropologist. As an undergraduate I remember reading his article, An Anthropology of Structural Violence. It took me by surprise.

Not because I was unaccustomed to scholars arguing that we need to link the ethnographically visible to history and political economy – or, in Farmer’s words, “the interpretive project of modern anthropology to a historical understanding of the large scale social and economic structures in which affliction is embedded”. No, my class had already read Sidney Mintz. It was somewhat fascinating to read an anthropologist who at the same time was a doctor committed to heal the sick in his ethnographic surroundings. But that’s not really what got me, either. 

What startled a young student was Farmer’s unorthodox reply to the comments section of his article. A whole A-Team of academics had come out – Nancy Scheper-Hughes, Linda Green, Didier Fassin and others – giving careful and polite criticisms to the arguably crude concept of “structural violence”. Farmer’s short reply broke the mold. It took no effort to amend the purported weaknesses of his own argument, or to point out inconsistencies among his critics. It made no attempt to elaborate his vision for the discipline. Rather, Farmer remarked that “the concept of structural violence may or may not prove useful, and the criticism offered by my colleagues is instructive and welcome.” He went on to describe how human suffering in Haiti had become increasingly acute since the paper had been published. A recent coup d’état compounded the already stark consequences of a US aid embargo to Haiti. Thus, without excuse, Farmer concluded that

These conditions, which directly affect my clinical work, preclude a more extended consideration of my colleagues’ commentaries but do not lessen my gratitude for both the forum in which to air these views and the clarity of these responses.

Put otherwise: “As a physician, there are times when academic discussion stops being useful. That time has now come. Kind regards, Paul.” When I recently met with Dr. Farmer, he seemed amused that I remembered his response. “Yes, that’s exactly what I said!” he told me with a smile, as we sat down before his guest lecture at the University of Oslo.

Paul Farmer: What I said was that structural violence, it’s just a concept. We’ll get another one. I am not wed to it. “I find it useful, and I find your critique useful. Thank you.” That’s how I feel. I feel that critical thinking is always important as a matter. And if a concept isn’t useful to someone, they should find a new concept. We should all find new concepts.

When you say you were surprised in reading my response, I hope you were somewhat pleased? Because the real fight is against poverty and injustice. And there are lots ways to have a clear analysis of it, and to have a strategy to addressing poverty and injustice in lots of different ways. But you know, to be wed to a concept or an academic theory is dangerous. That’s a 19^th century trap. I wouldn’t recommend it to you as a student.

I hope some of your other teachers are saying that. Because what teachers are usually saying is “I want you to be wed to my theory.” I am saying, “I won’t do that”. It’s a theory! It’s an idea! And it’s important to have ideas. There are a lot of power in ideas and concepts. But that’s not the only thing that we should do. We should also be very concerned with the pragmatic needs of people all around us, and as I have said those are food, food security, basic health services, public safety.

Anthropology of Health Economics

SW: What role do you see for a critical anthropology, or a critical social science, which is able to contribute positively to its surroundings?

PF: Well, my favorite anthropologists are all doing that already – Nancy Scheper-Hughes, Arthur Kleinman, Unni Wikan. That is also what I try to do, to say “what is the big picture here, how do institutions work in ways that lift people from poverty or do not?” That is the overall question I am interested in. So that’s a very constructive role to take.

SW: Are there particular topics which you would like to see more students address?

PF: Yes. What about a critical anthropology of health policy or health economics? I am still waiting for that. For example, there should be a lot of people writing PhDs about how notions of cost-effectiveness are deployed in settings of scarcity, and then they should pick apart the notion of “cost” and the notion of “effectiveness”. But I haven’t seen those studies yet.

How can you say something is cost-effective, if you don’t understand “cost” or “effectiveness”? It is two powerful words hung together by a hyphen. We have to be very careful when we claim that something is cost-effective or cost-ineffective, if we haven’t really even understood the cost of something.

In health policy, for example, we seldom hear anyone talking about the cost of inaction. Let us consider how much it costs to do nothing about, say, treating AIDS if it is already the leading infectious killer of young adults in the world, which it was in 1999, when it surpassed tuberculosis. What does it cost not to have a health equity plan? A lot. We need to figure out the cost of inaction – a topic which is much understudied. Action has cost, but so does inaction.

To me it’s urgent that we understand this prevailing ideology of cost-effectiveness, because it has terrifying real-life consequences.

Biosocial complexities

PF: But generally I think some of the critical thinking is not as critical as it thinks it is.

SW: In what sense do you mean that?

PF: Well, to me the only way to have real critical thought is to understand various forms of outcome. Let’s take an example from Russia. In 1998, on the 50^th anniversary of the universal declaration of human rights, I was in Moscow. A debate was going on; there were some Human Rights experts, mostly lawyers, and some people from the prison system, generals in uniforms. And there was a big debate going on between them about why a lot of young people were dying in detention. And the experts who thought they were being critical were saying “these young people are dying of starvation”.  And the people in the prison system were saying “no, they are not.” They weren’t. They were dying of multi drug resistant tuberculosis. The self-defined progressives had no clue what was going on bio-socially. And there is a lack of that multi-disciplinary understanding, unfortunately, in much critical thinking. These analyses are weak, superficial and disciplinarily enclosed. They are unable to understand the biosocial complexities we face today.

Now, to me, any critical analysis in medical anthropology, which tries to understand the real dynamics of suffering and poverty, needs to understand such things as the workings of drug resistant tuberculosis. That to me is real critical anthropology: It understands political economy, it understands how power works, it understands how embodiment happens, it understands how airborne and waterborne diseases and are actually transmitted – it understands all those things, and is sophisticated in a way that could not have happened without many of the tools that are unconventional in today’s anthropology, such as lab data. All of these things are part of what you need to make any reasonable claim to causality.