Infections and Inequalities: The Modern Plagues

  • Paul Farmer
University of California Press, $29.95 344 pages, 1999 ISBN: 0-520-21544-3 | ISBN: 0-520-21544-3

Read this passionate book by Paul Farmer and be impressed, once again, that tuberculosis is a great disease. It is both the result and the cause of great human misery. It has inspired great science, medicine and literature. Think of Dostoevsky, the Bronte sisters, Keats, Lord Byron, Henry James and Thomas Mann. Think of those towering works and figures of literature, and be misled. They show the well-to-do dying of tuberculosis. They did, but tuberculosis always affected the poor more than the rich. Paul Farmer reports that in the 1830s, English mortuary registers revealed that "the proportion of consumptive cases in gentlemen, tradesmen, and laborers was 16, 28, and 30% respectively."

How are we to account for the link between social conditions and morbidity and mortality from tuberculosis? Debates surrounding this topic typify and probably are responsible for many of our ideas on disease causation. Let us consider the four most prominent ideas: genetic susceptibility, social misery, infection with the tubercle bacillus and its variants, and poor compliance with treatment.

First, we did not need the developments of molecular biology and the human genome project for medical science to speculate on genetic causes of variation in disease susceptibility. In the last century in the American South, the higher tuberculosis rate in blacks than whites was thought to be due to differential susceptibility that was genetically determined. Then still, in the 19th century, American scientists posited an alternative to the hereditarian view: excessive TB mortality rates were attributed to general insalubrity of sections of cities, crowded conditions of dwellings, insufficient nourishment and other influences of poverty.

Next came Robert Koch's discovery of the tubercle bacillus in 1882. Farmer quotes Koch: "One has been accustomed until now to regard tuberculosis as the outcome of social misery and to hope by relief of distress to diminish the disease. But in the future struggle against this dreadful plague of the human race one will no longer have to contend with an indefinite something, but with an actual parasite." As McKeown documented a generation ago, knowledge of the parasite, although it was an important scientific breakthrough, was not responsible for the decline in TB mortality in industrialized countries. It was, in fact, relief of "social misery" that led to TB mortality's drop down the tables of leading causes of death in developed countries, and also from modern novels and poetry.

Tuberculosis did not disappear, of course; it only slipped from the consciousness of people in rich countries. Farmer's thesis is that it is the persistence of poverty and social inequalities that led to a greater death toll from tuberculosis in 1995 than in any year in recorded history. In 1996, more than 3 million people worldwide died of tuberculosis, and it has been estimated that 2 billion people, one-third of the world's population, are now infected with TB. Gaining a greater understanding of the pathogen is essential to the development of specific and effective antimicrobial therapies, but this has not led to the eradication of tuberculosis. This has led to a fourth view of the causal links with TB: that treatment of tuberculosis is unsuccessful among the poor because of their poor compliance with therapy. Farmer, a clinician, medical anthropologist and Harvard professor of infectious diseases, is scathingly critical of this view. "Throughout the world," he writes, "those least likely to comply are those least able to comply." We should not exaggerate the amount of control that poor people have over their lives. He calls this error "exaggeration of agency."

For the past 15 years, Farmer has spent half of his year working in rural Haiti and in shantytown Peru. The world view he portrays in the book is shaped by his front-line medical experience, ethnographic studies and knowledge of scientific literature. He states that the high prevalence not only of tuberculosis but also of HIV infection in the world is the result of two forces: poverty and social inequality. Farmer is critical of the blind spots of his anthropological colleagues, claiming that their pre-occupation with the exotic nature of cultural differences have caused them to "miss the revolution"—or fail to recognize the pathogenic effects of poverty and inequality, what he calls "structural violence." He is critical, too, of medical colleagues who fail to recognize the operation of large-scale forces that generate sickness. His studies of HIV infection among women in rural Haiti reveal that few of his cases have the "standard" HIV risk factors, but that HIV "tracks along the steep gradients of power."

Farmer emphasizes that he is not anti-medical—he does not question the importance of 'bench science'; nor is he a Luddite, opposed to medical intervention until society's problems are solved. For Farmer, there need not be a trade-off between learning the underlying structural causes of widespread infectious agents and dealing with the problem now. Based on a small study in Haiti, he suggests that financial and nutritional assistance make a substantial difference to the ability of poor people to cooperate with therapy, and that successful therapy for TB is possible even in settings of extreme poverty in which hospital-based care is unavailable.

The strength of this book is the combination of the author's trenchant analysis, his undoubted academic credentials and his front-line experience as clinician and anthropologist. When economists tell us that a human life is less valuable in a poor country than in a rich one, we must acknowledge that those of us in the rich world certainly behave as if this is so. Farmer's account is aimed at reducing people's comfort with that position. He emphasizes that for TB, we do have the medical and financial means at hand to make an impact on the problem now. What we lack is the will. Farmer is less sanguine about HIV. He speculates that economic structural readjustment programs, such as those promulgated by the International Monetary Fund, may be making matters worse. Such programs, by limiting government spending, commonly have adverse effects on those who are already the worst off. This critical analysis is a good starting point for physicians, politicians and scientists to take a serious look at current health, social and economic policies. It is recommended reading for all concerned with applying medical science to improve the lot of humanity.