Scatter-shot efforts, no matter how innovative, will not suffice to reverse the awful trends now evident around the world. New plagues — AIDS, drug-resistant tuberculosis and hospital-acquired “superbugs” of all sorts — sweep rapidly across vast swathes of land, blurring national boundaries. Old maladies that should have been history, like smallpox, remain rooted in long-standing and increasingly unjust social and economic structures. Malaria, hookworm and other parasites claim lives or simply drain energy from hundreds of millions; it’s hard to work when you’re tired and anemic or pregnant a dozen times before the age of 30. There are still rich people and poor people, but most economists agree that social inequalities, both global and local, have grown rapidly over the past three decades. The earth itself is tired and malnourished. Man-made environmental crises dry up lakes, wash topsoil into the seas and smother reefs, and — from what we can tell — spark huge storms. A billion people do not have safe drinking water. A war built on lies will cost, one Nobel laureate economist tells us, three trillion dollars.
What cause have we for hope? As a doctor working in Africa and Haiti, I see first-hand just how wide the technology gap is. It’s more of an abyss than a gap. Yet I feel hopeful.
Some of that hope is tied to an increasing awareness of the great world around us. There is, as is often reported by cheerleaders of commerce, vast and rapid growth in the global economy. China and India, not so long ago poor and agrarian, are already economic powerhouses and these economies continue to grow rapidly, if unevenly, and if fueled by coal and oil. With 50 years of peace, Europe is more prosperous than ever. In spite of trade imbalances, a recession, and imprudent wars built on lies, the United States remains rich and is still an incubator for new ideas and novel technologies. And here is another cause for hope: our citizens, if famously ill-informed about the world, are generous: almost half of American households responded to a tsunami in Asia, more than any other nation, and even more tried to respond to the worst hurricane ever to hit our country’s Gulf coast.
Haiti’s ‘rice wars’
If you’ve been reading the paper recently you will have seen news of the food riots happening in Haiti. This is not just a problem of rampant malnutrition — though that is of course a huge problem in most of the country. It is, rather, a problem of global collusion, unfair trade agreements, and crazy agricultural subsidies.
I was in Haiti during the years the country was pushed, by countries with their own ridiculously high agricultural supports for rice and others cereals, to drop import tariffs on rice and sugar. Within less than two years, it became impossible for local farmers to compete with what the Haitians called “Miami rice.” The whole market in Haiti fell apart as cheap, U.S.-subsidized rice — some of it in the form of “food aid” — flooded the market. There was violence — “rice wars” — and lives were lost. Within that time, Haiti, once the world’s largest exporter of sugar and other tropical produce to Europe, began importing even sugar — from U.S.-controlled sugar production in the Dominican Republic and Florida. It was terrible to see Haitian farmers put out of work, and all this sped up the downward spiral that led to last month’s food riots.
Within a decade of all of these pressures to “open up Haitian markets,” Haiti was still under intense pressure from the so-called international community to privatize. In the mid-’90s, when U.S. support for President Aristide’s return was linked to continued privatization and removal of any trade protections that might have helped the farmers — most of them working small plots of land — become competitive, Oxfam declared Haiti’s economy one of the most “open” in the world. This at a time when U.S. agribusiness continued to enjoy ludicrous levels of subvention.
This is an awful story that is hidden away from all the headlines of rioting Haitians, and it reminds us that no one group of innovators, not even agricultural whizzes who can come up with drought-resistant, super-high-yield, supersize-me maize or wheat, will be enough to solve the global problem of food insecurity. It will require technical innovation and a movement for social justice. That’s what we need to build here, and what the generation now in college needs to take on.
Why we must preserve the public sector
Medicine and public health will not solve the world’s problems, but can offer part of the solution to some of them. What’s been shocking to me over the past 25 years is the lightning speed at which many policymakers decide that a complex intervention is “too difficult” or “not cost-effective in Haiti or Africa,” or “not sustainable.” In microfinance parlance, many of my patients are “poor credit risks,” but aren’t they the very people we claim to serve in the first place? How many times have you heard that people will value something more if they pay for it? Does anyone really believe that a mother loves her newborn more if she had to pay some sort of users’ fee to access prenatal and obstetric care?
Let me be clear: this is not an “anti-market” stance. It’s merely the argument that market alone will not solve the problems of adequate housing, nutrition, employment and educational opportunities for those who need them most. It’s the argument that even the best and most needed technologies will not somehow be magically spread across the poorest parts of the world simply because they are innovative. It’s the argument that we need to do everything in our power to make sure that the public sector does not shrivel and die. Why? Not only because a functioning public health or education system is often the only way to bring a novel program to scale, and not only because we need the participation of governments to address the current environmental crises at the transnational scale needed to make a difference. There is another reason to fight the neoliberal gutting of the public sector, and that is this: only governments can confer rights. And without basic rights — to water, security, health care, the right not to starve — the world’s poor do not have hope of a future.
Enlarge the meaning of human rights
The funny thing is that, among self-proclaimed human-rights experts, these socioeconomic rights tend to be the neglected stepchildren: the focus in what we call “the West” is largely upon civil and political rights. We should not give up on the rights paradigms, but rather enlarge them to include what many call the rights of the poor. Water. Food. Health care. Jobs. Education.
When effective treatment for tuberculosis was developed, it would have been a good idea to make it available to anyone with tuberculosis, regardless of social station. To sell treatment for an airborne disease was not smart, since those who could pay might get better but those who could not would buy what they could and then develop drug-resistant TB. Public health experts, uncomfortable with the notion of a right to health care, began speaking of “public goods for public health. Here was an airborne disease; it was a public problem, not a private one. A hard-won lesson.
Then came a change in the culture. Instead of “health for all by the year 2000,” we had “structural adjustment” imposed by the international financial institutions that today claim amnesia regarding these events. There is still no admission that it is wrong, in settings of great squalor, to insist on “user fees” or “cost recovery” from the poorest.
Our last great hope
We need to link our rights-based arguments to more subtle and honest notions of sustainable development, and to sell these to leaders of good will. Bertolt Brecht, who is almost always right, has argued that “the compassion of the oppressed for the oppressed is indispensable. It is the world’s one hope.” I fear that, at this late date, an additional kind of solidarity is necessary. A social justice movement that links the rich world and the poor, one that links concern for the earth with respectful solidarity towards its poorest inhabitants, is our last great hope for a world marked by less suffering and violence and premature death. It’s our last great hope for the generations to come, and for our own children.
But we need hope and courage and a plan to end, for example, an unjust war. We need hope and energy to tackle the diseases that should have been wiped out decades ago or never allowed to spread so rapidly. We need hope and sheer grit to spread green technology and food security to the poorest parts of this planet. We need hope to counter the neoliberal policies that have weakened and even wrecked public-sector institutions without ever delivering on the promise to lift all boats. We need hope to speak to people in powerful positions whose hearts, unlike the polar icecaps, show little signs of melting. We need hope, and we need each other.
Paul Farmer, M.D., Ph.D., is Presley Professor and Associate Chair, Department of Social Medicine, Harvard Medical School; Associate Chief, Division of Social Medicine and Health Inequalities, Brigham and Women’s Hospital; and a co-founder of the nonprofit organization Partners In Health (www.pih.org). This article is excerpted, with permission of the author, from a recent address delivered at the Inaugural Millennium Campus Conference, Global Poverty Initiative, at the Massachusetts Institute of Technology.