Infections and Inequalities, by Paul Farmer

November 20, 2001

What causes disease? Is it germs? Or people? This book about the global plagues of AIDS and tuberculosis says that, in the end, people do. For the most part it is society, not microbes, that determines where infectious diseases will break out and how well those infected will fare.

When the plague hit Europe in the 14th century no one knew how to stop it. Many do know how to stop the plagues afflicting us now. Yet the question is: Will we? Infections and Inequalities shows how we can go about doing so and why it is vital for us to do so.

Paul Farmer, a physician-anthropologist, asks why medicine cares so little about the sicknesses that afflict the poor and why anthropology so frequently ignores suffering and oppression. He makes a strong case for fighting infectious disease from a radically new vantage point. Poverty and powerlessness, Farmer stresses, are the strongest pathogens on earth. His message is urgent and relevant for saving millions of lives.

The staff of the World Health Organization makes a distinction between the "doctors" and the "engineers" among them. The first group works to cure diseases in people. The second manages environmental risks, such as water-borne diseases. Farmer is both doctor and engineer, plus something more--an advocate for justice for the poor. For nearly 20 years, he has divided his professional life between Harvard Medical School and a rural clinic in Haiti.

"Health care for the poor struck me, early on, as the noblest goal a physician could have," Farmer writes. He was drawn by the "unarguable immediacy of [the needs of the poor], and the vitality of practice of those seeking to meet them." That he spends part of each year in two worlds is jarring, he notes, but also illuminating.

Farmer describes the power human beings give to viruses when they protect and cure some people while leaving many others vulnerable. The vastly different health outcomes for privileged and unprivileged people are "biological reflections of social fault lines." Crushing inequalities make the same infection, HIV or tuberculosis, a very different malady depending on where the infected person lives in the world and who that person is. Farmer uses clinical medicine and social theory to link "molecular epidemiology to history, ethnography, and political economy." The synthesis of social and biological approaches to illness is "easy to demand but harder to produce," he notes. Yet failure to do so is costing countless human lives.

During the past 150 years progress in medicine has come largely at the biological level rather than at the social. Breakthroughs in the laboratory avail little against breakdowns in society. In fact, when biomedicine creates complex and expensive remedies--like protease inhibitors--science widens the gap between rich and poor even as it saves a relative few from an early death. "Nothing is wrong with high-tech medicine," Farmer writes, "except that there isn't enough of it to go around."

This book asks readers to examine their view of the world. Many people exaggerate the role of the poor in causing their own illnesses. If we are relatively privileged, it is common to see poverty, suffering and inequality almost as "cultural" differences between them and us. Perceptions contribute to the career of a disease. Leprosy comes readily to mind--an illness so demonized by legions of Sunday school teachers, and even scripture itself, that we still have to remind ourselves it is curable. AIDS has already been inducted into the same Stigma Hall of Fame.

Farmer also raises basic questions about circumstance. Why do poor people get TB more often than rich people and, once sick, get sicker? Why has TB stayed in the shadows, while AIDS has grabbed the headlines? Where would AIDS be on the planetary radar screen if it had not infected rich people as well as poor? And, the biggest one of all: "How do life conditions restrict any individual's capacity to make choices?"

Digging into the data, Farmer found that in the late 1980s women were mentioned in only 2,000 out of 100,000 references to AIDS in the scientific literature. When he searched "poverty" as well, there were no references to women at all. (Later he edited a book called Women, Poverty and AIDS. The topic is crucial for AIDS strategy.)

Farmer describes a peculiar stress within himself like that which tears at the heart and mind of aid workers. It's as if angst competes with catharsis. One finds an endless source of angst in the various systemic failings that seem to work against the world's poor. At the same time, catharsis comes from taking remedial action at the local level.

Though Farmer says that he and a colleague followed liberation theology in choosing a "preferential option for the poor," his references to religion are oblique. Because he has honed his message for his peers his book contains 85 pages of footnotes and references. But for scientists and others of faith, this important study knocks at the door of a deeper, broader and more political discussion which it does not enter.

Farmer might be called a medical missionary for the 21st century, a physician-prophet in an era in which infections and human responsibilities are increasingly globalized. It has become less and less plausible, as the information age wears on, for anyone to plead ignorance over questions of such magnitude. His book reminds us of how faith must challenge fatalism, of what is in God's hands, and of what we humans hold in ours.