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ISBN-13: 978-0520229136
ISBN-10: 0520229134
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Editorial Reviews

From Library Journal

Farmer is a physician-anthropologist who directs the Program in Infectious Disease and Social Change at Harvard Medical School. He also has clinical practices in Boston and in Haiti, where he has done extensive fieldwork with Haiti's rural poor. Aiming to explain why infectious diseases such as AIDS and tuberculosis target the poor, he fills his new work with harrowing public-health case studies of the pathogenic effects of poverty and other grim social conditions. Farmer provides a well-referenced analysis of everything from cell-mediated immunity to healthcare access issues. The studies outlined show that extreme poverty, filth, and malnutrition are associated with infectious disease and what attitudes and behaviors contribute to the lack of understanding about disease. Arguing that the predictors of patient compliance are fundamentally "economic not cognitive or cultural," he builds a powerful and persuasive argument for a proactive multinational program to defuse the "infectious disease time-bomb." Highly recommended for all medical school library collections and any collection concerned with public-health issues.ARebecca Cress-Ingebo, Wright State Univ Libs., Dayton, OH
Copyright 1999 Reed Business Information, Inc. --This text refers to an out of print or unavailable edition of this title.

From The New England Journal of Medicine

What causes tuberculosis in humans? In the late 19th century, the German microbiologist Robert Koch thought the answer was unambiguous: the tubercle bacillus, which he discovered in 1882. Since then, Koch's laboratory model of the transmission of infectious disease, subsequently articulated in eponymous postulates, has dominated explanations of the causes of infectious diseases. Nonetheless, as early as the 1890s, some physicians expressed doubt about the adequacy of any laboratory model for explaining the vagaries of communicable disease in humans. For example, during a debate in 1894 on the advisability of public registration of persons with tuberculosis, William Osler observed that a person's "material condition" rendered him or her "more or less immune." He continued by offering an analogy: in clinical tuberculosis, the "soil, then, has a value equal almost to that which relates to the seed."

In Infections and Inequalities, Paul Farmer, who was trained in both infectious diseases and anthropology, uses these disciplines and his medical experience in Haiti to provide a trenchant analysis of the biologic and social realities of chronic infectious disease.

For Farmer, the causes of tuberculosis and AIDS, the two epidemics this book addresses, have as much to do with social inequality as they do with microorganisms. Using data mostly from Haiti, where he has worked since 1983, in addition to data from the United States and Peru, Farmer argues that social and economic inequalities "have powerfully sculpted not only the distribution of infectious diseases but also the course of health outcomes among the afflicted." The pathogenic agency of inequality is so great, Farmer maintains, that "inequality itself constitutes our modern plague," a statement he seeks to demonstrate in the balance of the book. In doing so, he repeatedly acknowledges the work of his mentor Arthur Kleinman, economist Amartya Sen, epidemiologist Richard Wilkinson, and others whose work in a variety of disciplines over the past two decades has focused attention on inequality and lack of social cohesion and their adverse effects on health. There are two distinctive aspects of Farmer's approach. First, Farmer has been a social activist since the early 1980s, when, as a medical student doing elective course work in Haiti, he began a long-term project to improve the health of rural Haitians -- the Clinique Bon Sauveur, which now sees more than 30,000 patients per year and trains hundreds of Haitian health care workers. Second, Farmer uses his experience as an activist to discuss critically the conventional wisdom about anthropology and infectious disease, specifically the causes of emerging infection.

Anthropological analysis falls short in explaining the causation of disease, Farmer argues, when it emphasizes personality and culture but slights barriers to the delivery of health care. For example, he takes aim at anthropologists who explain the failure of tuberculosis-control programs among poor Haitians as the result of either an inadequate understanding of local culture on the part of the practitioners or the supernatural beliefs of the locals, or both. It is not that cultural analysis is unimportant, Farmer writes, but rather that it misses the point when it does not place cultural perspectives in a socioeconomic context. Among patients in Haiti's rural Central Plateau who were offered free and convenient care for tuberculosis, compliance and outcome were strongly related only to nutrition and income and not to beliefs about the cause of the illness.

Farmer also derides the anthropological studies of the 1980s that explained the emergence of AIDS in Haiti as the consequence of "exotic" indigenous practices such as voodoo. Instead, Farmer argues, these researchers should have emphasized local and regional socioeconomic conditions that impeded effective care and promoted dissemination of the human immunodeficiency virus. Emphasizing the role of culture, and not the roles of poverty and inequality, in infectious disease can even cause harm. Exaggerating the importance of individual actions may cause makers of public health policy to ignore effective measures for improving health care.

Although Farmer thinks epidemiologists are generally alert to the role of social factors in emerging infection, he also believes that their typical unit of analysis, the nation-state, tends to obscure the disproportionate damage that infections wreak on poor communities in larger jurisdictions. For example, in 1992 the rate of tuberculosis in central Harlem, New York City, at 222 cases per 100,000 population, exceeded that of many Third World countries, a fact that disappears in the epidemiologic profile of tuberculosis for the entire United States. As a countermeasure, Farmer promotes a "critical epistemology" of emerging infectious diseases that explores in detail how poverty and inequality cause infectious diseases to emerge in specific local contexts. Hypothetical questions formulated with this approach might include the following: "By what mechanisms have international changes in agriculture shaped recent outbreaks of Argentine and Bolivian hemorrhagic fever, and how do these mechanisms derive from international trade agreements such as GATT [the General Agreement on Tariffs and Trade] and NAFTA [the North American Free Trade Agreement]?"

Farmer answers the questions he poses by mixing his theory and epidemiologic data with numerous personal anecdotes of his encounters with patients, an approach that renders his account poignant. Infections and Inequalities consists of 10 chapters, half of which are essays that were published from 1990 to 1996 in books or journals. Instead of sustained discussions of structural violence, inequality, tuberculosis, AIDS, and other important themes and subjects, the reader encounters numerous short passages on the same subject or theme in different essays. This is a loss, since the redundancy and lack of sustained exposition of some of the book's important themes, aside from making for occasionally choppy reading, mean that definitions of some of Farmer's key concepts, such as structural violence, remain implied rather than explicit.

Robert L. Martensen, M.D., Ph.D.
Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS. --This text refers to an out of print or unavailable edition of this title.


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Product Details

  • Paperback: 419 pages
  • Publisher: University of California Press; Updated edition (February 23, 2001)
  • Language: English
  • ISBN-10: 0520229134
  • ISBN-13: 978-0520229136
  • Product Dimensions: 6 x 1.1 x 9 inches
  • Shipping Weight: 1.4 pounds (View shipping rates and policies)
  • Average Customer Review: 4.3 out of 5 stars  See all reviews (23 customer reviews)
  • Amazon Best Sellers Rank: #201,546 in Books (See Top 100 in Books)

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More About the Author

Paul Farmer is UN's Deputy Special Envoy for Haiti and Chair of Global Health and Social Medicine at Harvard. He is also Professor of Anthropology at Harvard Medical School, chief of Social Medicine and Inequalities at Boston's Brigham and Women's Hospital, and founding director of Partners In Health. Among his numerous awards and honors is the John D. and Catherine T. MacArthur Foundation's "genius award."

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Most Helpful Customer Reviews

79 of 83 people found the following review helpful By Jonathan Joseph, MD on June 8, 2000
Format: Hardcover
Finally Dr. Farmer couples his lucid historical, political and economic analyses of the conditions that put the poor at risk for bad health outcomes, with a plainly indignant calling out of healthcare professionals and healthcare organizations to make honest efforts to understand and remedy conditions which would never be tolerated among the well off in Western nations. In his goundbreaking, earlier books, "AIDS and Accusations," and "The Uses of Haiti," Dr. Farmer matter of factly discusses the global and local structural conditions and misrepresentations which led to the spread of disease and persistent, dismal health conditions in Haiti. In "Infections and Inequality," Dr. Farmer adds moral overtones to incisive, sociopolitical analysis and his characteristic accounts of individuals suffering from disease. The book consequently provides a powerful reflection from a man who has worked in some of the world's poorest regions on what the benefits of medical technology mean for people who have not traditionally had access to them. A powerful, informative read that clearly reflects the years of experience of a physician who has wrestled with the global responsibility of caring for the those who are worst off. An obligatory read for anyone even thinking of working for the impoverished of the world.
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33 of 34 people found the following review helpful By Andrea Ducas on January 1, 2004
Format: Paperback
Dr. Farmer sums up what you can hear in his lectures (he is an amazing speaker), read in journals, and hear in his interviews: The "modern day plagues" result directly from Structural Violence. I read this book for my culture and health class and could not put it down. He writes with an eloquence unheard of in most anthropologists while at the same time with the passion of a deeply concerned physician. Although in some points the book can get repetitive (as case studies overlap) it is a spectacular, enlightening read that I would recommend to anyone, particularly potential (and current) medical anthropologists.
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Format: Paperback
Farmer, a physician-anthropologist and activist, examines both the way that poverty and inequality result in the spread of HIV and TB today and the flawed justifications for inequitable access to treatment. His ethnographic analysis provides a powerful complement to standard epidemiological work, and this treatise on the danger as well as the immorality of inequity in medical care is largely convincing.

Farmer illustrates several broad themes effectively with case studies from Haiti and Peru. One is the idea that most studies overemphasize individual agency, failing to recognize serious "structural" factors, such as the pressure that extreme poverty exerts on people to engage in unhealthy behaviors and the problems introduced by economic inequality. (One example of the latter is that in unequal countries like Peru, second-line TB drugs are available because of demand by the rich, so doctors also prescribe them to the poor who can only afford them intermittently, which generates drug-resistant strains of the disease.) Another theme is that people in rich nations tend to place heavy weight on "strange" cultural beliefs and customs in explaining high disease prevalence, whereas actual epidemiological research tends to show that these factors carry little weight relative to poverty-related factors. While he uses AIDS in Haiti to illustrate this tendency, it applies perfectly to popular Western conceptions of AIDS in Africa: the popular media tend to emphasize cultural practices such as wife inheritance and a strong sex drive, whereas epidemiological research fails to support a major role for these.

A third theme, which Farmer often trumpets but not as convincingly, is that many of the trade-offs voiced by policymakers are ultimately false.
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6 of 7 people found the following review helpful By K. B. Dozier on May 9, 2008
Format: Paperback
An enlightening and insightful book that passionately sets a higher standard for those involved in medicine or any type of humanitarian work. He is passionate about what he says, but careful not to make assumptions that have not been well documented and researched. The book challenged my thinking when it comes to health care, poverty, and our social duty to take action against injustices in the world.
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7 of 9 people found the following review helpful By Mary E. Sibley VINE VOICE on June 20, 2008
Format: Paperback
The context of epidemics is important. What happens to the poor people who have drug resistant tuberculosis? Market mechanisms do not serve the interest of global health equity. The cost-efectiveness argument is weak. Poverty limits freedom of choice. AIDS education falls short. Arguments about limited resources should not prevail. There is a global web of unequal relationships. Structural violence and cultural difference have been conflated in AIDS studies.

Anthropology and medicine have blind spots. Virchow understood medicine had biologic and social underpinnings. There is not enough high-tech medicine to go around. Inequality itself is a pathogenic force. The author's interpretation of modern plagues has been shaped by work in Haiti and Peru. As scientific and medical communities tried to make sense of AIDS, the author was drawn into the discipline of the sociology of knowledge. World systems theory, one of the newer anthropological theories, could posit that Paul Farmer of Harvard and Haiti is a conduit for resources.

In many instances of disease emergence, social topography is more important than geographic topography. The differential political economy of risk is described. The major risk factor for AIDS is poverty. Personal agency has been exaggerated. From typhoid to tuberculosis to AIDS, blaming the victim is a theme in the literature. Being sick results from structural violence, not from bad personal choices. The author lived in a village in rural Haiti when both AIDS and political violence arrived. Haitian cases of AIDS defied the risk-grouping descriptions prevalent in the 1980's. The Haitian epidemic of AIDS originated in the United States.

Recent circumstances in Haiti include deepening poverty, gender inequality, instability.
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