Infections and Inequalities:
The Modern Plagues

Paul Farmer

University of California Press 1999
A book review by Danny Yee © 2006
Infections and Inequalities is a passionate call for rethinking approaches to infectious diseases in poor countries. It has been reworked from previously published pieces, resulting in a fair bit of repetition and an overall structure that's not as effective as it might have been, but it is powerful and provoking nonetheless.

Farmer begins by telling something of his personal story, moving backwards and forwards between Haiti and Boston, between a clinic in a poor rural area on Haiti's central plateau and Harvard Medical School. He then suggests a rethink of ideas about "emerging infection diseases" such as Ebola, TB and HIV, arguing for an emphasis on inequality, transnational perspectives, and a biosocial approach informed by a critical epistemology.

There are four chapters on AIDS. One presents case studies of three individual women, from Harlem, Haiti and Bombay, and debunks some of the common myths about women and AIDS. Another tackles "the geography of blame" and the way esoteric views of Haiti — voodoo, zombies, etc. — have been used in its demonisation as a source of AIDS.

AIDS in Haiti is about proximity, not distance. AIDS in Haiti is a tale of ties to the United States rather than to Africa; ... AIDS in Haiti has far more to do with the pursuit of trade and tourism in a dirt-poor country than with "dark saturnalia celebrated by 'blood-maddened, sex-maddened, god-maddened' negroes".

Two chapters focus on the Haitian village of Do Kay. One presents case studies of HIV infection and explores the dynamics of transmission: economic and population pressures, patterns of sexual union, gender inequality, political disruption, concurrent disease, and access to medical services. The other explores the cultural construction of AIDS (as sida):

[there are] three preexisting meaning structures into which sida neatly fits. The blood paradigm — which posits causal links between the social field and alterations in the quality, consistency, and nature of blood — was invoked early on... the tuberculosis paradigm has been invoked... Finally, the microbe paradigm, which has the official blessing of the local representatives of cosmopolitan medicine... is widely accepted, with provisions, throughout rural Haiti.

Farmer then turns to tuberculosis and the spread of multidrug-resistant tuberculosis (MDRTB). He begins with case studies from Haiti, Peru and the United States, the history of approaches to tuberculosis (where an early social emphasis changed to an individualised one), and different theories for the spread of MDRTB. One major problem is that medical practitioners and health systems persist in prescribing standard drugs to patients with known histories of resistance to them.

His experience with treatment in the Proje Vaye Sante community health program in Haiti highlights the importance of economic factors such as nutritional support and the transport costs to get to a clinic.

"The high cure rates we achieved also show that debates over whether to treat tuberculosis or to prevent it are essentially false debates, whose costs are borne, as usual, by the poor. Among those who correctly argue that poverty is the ultimate cause of tuberculosis, some make a serious error by advocating that development efforts should take precedence over tuberculosis treatment. ... this Luddite trap remains a peril of modern tuberculosis control. After all, we know how to treat tuberculosis, but development efforts often go awry."

And Farmer criticises "immodest claims of causality" by social science researchers who have put too much weight on cultural and psychological explanations, whether through romanticisation of "folk healing", or an emphasis on patient understanding of disease etiology and "noncompliance" — "the degree to which patients are able to comply with treatment regimens is significantly limited by forces that are simply beyond their control". This has led to a focus on education programs rather than on improving services, and to blame being assigned to patients rather than to structural problems. He also calls for less insularity and a "more crassly utilitarian" approach to research.

A concluding chapter criticises our failure to get antiviral drugs to HIV sufferers in the developing world and to tackle the "time bomb" of MDRTB. This is treatable (even in Haiti), not too expensive to treat, and no less infectious than ordinary TB; it can't be stopped just by treating drug-susceptible TB and should not be just ignored.

One major omission in Infections and Inequalities is any kind of economic analysis. Trying to formalise Farmer's ethical and political concerns would be tricky, but much of his argument is about effectiveness and efficiency, so some quantitative analysis of the benefits of different approaches to prevention and treatment would have added powerfully to his recommendations.

In a few places Farmer seems to be writing for his fellow practitioners, with the assumption of background knowledge — he refers to the Tuskagee trials and uses terms like "nosocomial" without explanation — but mostly the approach is non-technical and accessible to the lay reader. Infections and Inequalities is recommended reading for anyone involved with or curious about international health issues and infectious diseases.

June 2006

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%T Infections and Inequalities
%S The Modern Plagues
%A Farmer, Paul
%I University of California Press
%D 1999
%O paperback, revised edition, notes, references, index
%G ISBN 0520229134
%P xliv,375pp