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Citizenship Across Borders

By Professor Kanta Kochhar-Lindgren, Interdisciplinary Arts & Sciences, University of Washington, Bothell

What Can You Learn by Studying this Topic?

Following Paul Farmer’s example, what does it mean to engage in a citizenship across borders – one that articulates new spaces of social interaction, is responsive to unequal distributions of power, and leads to new models of engagement in the arena of local and global health? How might we use our discussion about Farmer’s example to develop our own understandings and practices of global citizenship, in general, and in relation to issues of health care, in particular?
This study note will help you:

  • understand Paul Farmer’s view on citizenship in relation to global health
  • think critically about citizenship across legal, political, and social categories in a global context
  • explore the implications of Farmer’s work for our own areas of social engagement

What is Citizenship?

In Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World, Tracy Kidder chronicles Paul Farmer’s socially active work to reform health practices for AIDS and TB in several international contexts such Haiti, Peru, and Russia, so that the poor can have better access to healthcare. Farmer’s work, an inspiring story about what one man can do to spearhead significant change, revolves around his ability to put together his understanding as a doctor with that of an astute social analyst in order to see how the medical problems are also connected to a systemic pattern of social injustice toward the poor, one he calls “structural violence.” In Pathologies of Power, Farmer writes that these “rights violations are . . . symptoms of deeper pathologies of power and are linked intimately to the social conditions that so often determine who will suffer abuse and who will be shielded from harm” (7) and “suffering is ‘structured’ by historically given (and often economically driven) processes and forces that conspire . . . to constrain agency” (40). Consequently, because this structural violence crosses national boundaries, it is important to rethink what our obligations are to each other as responsive citizens in a global society. Farmer models one such thoughtful and engaged response.
Farmer’s approach revolves around a certain notion of global citizenship. In other words, for him, national boundaries do not impose limits for helping one’s neighbor. For example, in Haiti, Partners in Health (Farmer’s non-profit research organization) and Zanmi Lasante (PIH’s sister organization) run a full scale medical facility with extensive outreach programs that Farmer started there in the late 1980s. To what extent, we might ask, does Farmer’s work provide us with a new model for global citizenship—one that is fluid, mobile across national boundaries, and yet deeply engaged in transnational social issues? What are the contours of this model? What are the possible scales of this type of model; in other words, what can we learn about this type of engagement from Farmer, and how can we shape it to our own contexts? How, from other angles, does this model fail to account for much smaller actions? Does this model need to be revised? In what ways does this emphasis on global health in places outside of the United States make it difficult for us to understand and engage with the local varieties of these issues of health disparities?

Understanding Citizenship

Citizenship, as a legal category, is a relationship between an individual and a state in which an individual owes allegiance to that state, and, in turn, is entitled to its protection as well as to certain rights and privileges. Consequently, citizenship, as a marker of national identity, often veils the ways in which this perspective makes it difficult for us to recognize those who are excluded from the rights and privileges of the state.
Additionally, citizenship can operate across national borders. The flow of immigration worldwide leads to fluid allegiances and mixed forms of governmentality. The global impact of capitalism and vast international communication networks also disrupts the sense of fixed state boundaries. Given the ways these flows of people, goods, and ideas create international webs of connectivity, it is useful to approach citizenship from an interdisciplinary view to fully comprehend its impact on global health care and allocation of health resources. In simple terms, Farmer’s work extends the analysis of Rudolf Virchow who wrote: “If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbances in mass life” (61). Farmer’s model challenges the tendency toward unequal distribution of healthcare and strives to render such a tendency obsolete.

Understanding Citizenship and Health Allocation

Farmer’s perspective directly links the issue of citizenship to health distribution. The citizens of Third World countries face a double predicament of economic stratification and health disparities. Farmer points to the example of Benedicta’s story, a poor woman who forgoes tuberculosis treatment to save her family from starvation. As Farmer points out, the risk of acquiring tuberculosis increases in a crowded, poverty-ridden area that encourages the spread of the disease. Afterwards, the economic limitations given to Third World nations limit the distribution of medical services. This situation can increase the spread of disease throughout the population to epidemic proportions. As we see in many of the examples in Mountains Beyond Mountains, both the failures of specific governments and international organizations and constituencies in terms of oppressive sociopolitical structures, poor information flow, and rigid ideas about international partnerships maintain the boundaries between the rich and the poor and increase the likelihood of the health disparities staying in place.

Citizenship and Health Allocation

To achieve proper health allocation in a global context, Farmer indicates that certain types of action are important. His view stems, in part, from liberation theology which argues for equal distribution of the world resources among its citizens. The poor citizens of the Third World, he argues, do not enjoy the benefits and services available to the rich or those in industrial countries because of socioeconomic discrimination. Therefore, curbing the spread of disease within Third World nations requires equal distribution of health resources, as well as a change in socioeconomic perspectives of industrialized nations. Yet, as Farmer’s work shows us, these changes will most likely come about one person at a time, one initiative at a time. Developing the social awareness that can inspire and lead to the process of making personal choices to act and get involved requires an evolving understanding of how we are all part of an international drama.

What Does This Topic Mean For You?

The analysis of citizenship in connection to health disparities increases one’s comprehension of what it means to be a global citizen. It helps increase one’s critical thinking and perspectives on socioeconomic policies by wealthy countries toward poorer countries. Also, it serves as a gauge to discern local, social issues such as homelessness and immigration reform. It is through struggling with such topics that we move, however modestly, toward personal and professional growth.

Questions for Further Study

  1. In a number of places, Kidder depicts Farmer’s colleagues as people who are exemplary in their work, but are not necessarily mega-stars in the way that Farmer is. What do you think about the way Kidder scrutinizes Farmer and his work and considers his approach as a model? Jim Kim, who has worked with Farmer for many years, comments, for example: “ ‘Paul has created technical solutions to help the rest of us get to decency, a road map to decency that we can all follow without trying to imitate him. …Paul is a model of what should be done. He’s not a model for how it has to be done’ ” (244). On the one hand, what’s useful and important about articulating the larger-than-life proportions and style of Farmer? On the other hand, how can a bit of skepticism help us to scale the model of engaged citizenship so that it better fits our own circumstances?
  2. What does Farmer want Kidder to hear when he asserts the following: “ ‘When others write about people who live on the edge, who challenge their comfortable lives – and it has happened to me – they usually do it in a way that allows a reader a way out. You could render generosity into pathology, commitment into obsession. …I don’t have a lot at stake in how you depict me’ ” (206-7). How does this quote help us to understand Farmer’s own ideas about his choices to make an impact? How do you think he might like us to respond?
  3. On a more personal level, do you have a passport? What does this passport entitle you to do, or make it difficult for you not to do? What type of global citizen can you be or not be because of your passport? Does this position impact what types of choices you can make as a socially engaged citizen? (How does the fact that Farmer is from the U.S. impact his international mobility?) Does this position impact what health services you have access to?
  4. What are your experiences with the medical system, locally or elsewhere? How do those experiences parallel some of the stories in Kidder’s book? How do they diverge? Why and how?
  5. What are the necessary conditions for a global citizenry that acts in responsible ways toward each other? How can we begin to get to this point?

Suggested Courses

UWB Discovery Core III (Spring): Citizens Across Borders: Politics, Healthcare and Art
Professor Kanta Kochhar-Lindgren

Resources for Further Study


Briggs, C.L. (2003). Stories in the Time of Cholera: Racial Profiling during a Medical Nightmare. Los Angeles: University of California Press.
Kidder, T. (2003). Mountains Beyond Mountains. New York: Random House.
Kim, J., Millen, J., Gershman, J., and Irwin, A. (Eds.). (2000). Dying for Growth: Global Inequality and the Health of the Poor. Maine: Common Courage Press.
Farmer, P. (1999). Infections and Inequalities: The Modern Plagues. Berkeley, CA: University of California.
Farmer, P. (2005). Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley, CA: University of California Press.


King, N. (2003). “Immigration, Race and Geographies of Differences in the Tuberculosis Pandemic.” In M. Gandy and A. Zumla (Eds.), The Return of the White Plague: Global Poverty and the ‘New’ Tuberculosis (pp. 39-54). New York: Verso.
Millen, J., Irwin, A., and Kim, J. (2000). “Introduction: What is Growing? Who is Dying:” In J. Kim, J. Millen, J. Gershman, and A. Irwin (Eds.), Dying for Growth: Global Inequality and the Health of the Poor (pp. 3-10). Maine: Common Courage Press.


Bill and Melinda Gates Foundation
Centers for Disease Control and Prevention
National Institutes of Health
Partners In Health
Robert Wood Johnson Foundation “Cover the Uninsured Week”
United Nations
World Health Organization
To learn more about the UW Common Book program, visit the Common Book website at: