Customer Reviews

Infections and Inequalities: The Modern Plagues, Updated Edition With a New Preface

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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.

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.

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. One example is the question of whether to treat tuberculosis with drugs or prevent it (e.g., by investing in economic development). He then uses the success of his clinic in Haiti as an example of both treating and preventing TB. The ultimate argument is that the wealthy have no right to withhold their wealth from the poor. However, he gives us no clear sense of how the resources to generalize this to the world at large should be marshaled. While the trade-off may be philosophically false, the practical application is unclear.

But even without a plan of action, Farmer illuminates key problems in the analysis of infectious disease spread and makes a convincing plea to share the wealth (and the technology).

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. The author and other physicians and health workers have learned that a belief in sorcery among Haitians does not preclude adherence to a biomedical regimen. Furthermore, high cure rates for tuberculosis, (often a twin affliction of AIDS), are possible in settings of extreme poverty. Juxtaposing treatment with prevention are false debates.

The author has traced the march of inequality as it affects health care in a myriad of ways. Endnotes and an extensive bibliography follow the text of this excellent work. Everyone should buy it, everyone should read it.

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.

The book took me by surprise. It was interesting, added emotion to hard evidence, and held with many opinions I have about the workings of global health.

If you are interested in public health and infectious diseases, this is a must read. Paul Farmer has a way of explaining things that just make sense and provides solutions that seem so simple.... if only it were that easy. There was little I could disagree with in this book, Dr. Farmer is spot on. This read is worth the time.

This book is a must read for anyone wanting to understanding how inequalities trap people into poor health. The contributions by Paul Framer are inspiring and should be read by everyone wanting to understand the true environment of inequality and infectious disease of the world today. A truly sad but eye opening book.

This book arrived on time and in excellent condition. It was also appropriately packaged. Thank You.

Anyone in the public health arena has heard (or even read) of Paul Farmer. The Harvard MD/PhD (Anthropolgy) is indeed a passionate and competant professional who has fresh drive and leads a commendable life in service to humanity. This book seems to be his most popular work (at least on campus of major public health colleges) and it deserves attention and analysis.

Farmer gives systematic treatment of HIV and TB etiology and prevalence in the US and Haiti. More importantly, how those diseases affect the poor in inequitable ways. Peppered with intimate anecdotes and cutting analysis, the book brings hard ideas with the immediacy of the individual plight. He debunks myth of AIDS early history and establishes perspetive for the disease to be viewed/studied in light of the poor and the strucutral violence that (he deems) causes the propensity of the disease in the lower levels of society. He offers solutions and pleas for attention to these 'new plagues' so that the effects can be mitigated for the sake of all humanity.

There are some issues with that perspective. Of course every author brings inherent bias to the writing (either intentional or not), but Farmer makes no apology for his worldview and dismisses opinions of others who are even within the sientific community as he. John Stuart Mill (in "On Liberty") would say that such an attitude is likened to assuming infallibility (which Farmer more or less accuses the attitude of the 'rich' toward the modern plagues). His neo-Marxist tendency completely undermines the state of the world and he therefore addresses his problems from a "the way it should be" approach. That is his prerogative, but taking such an attitude means that his ideas will remain just that: ideas. His lack of pragmatism borders a silent taint of militarism and that approach rarely attracts policy makers, even those on the left.

Farmer assumes that a preponderence of evidence precludes a serious analysis of personal aganecy. No one would argue the conflict of structural violence and the inherent effects on personal agency. Yet, the fact remains that it does exist and it at least needs to be addressed in a thorough matter in order to be a fair treatment of the subject matter.

Furthermore, he needed to address the distal factors (i.e etiology and biology of the diseases) with the proximate (i.e. socio-econimics, etc...) for the book to be of more interest to the lay person. Despite my reservations, it is still a great book to get the reader "out of the box" and see AIDS and TB with the urgency it deserves. Yet, this type of book needs to be in the hands of the lay, and this recommendation would help.

Lastly, Farmer claims on several occasions a foundation of political economy in the analysis of his subject. He is a physician and anthropologist, and without the concurrent opinions of a political-economist to back up his claims, the ideas therein are weak at best. His political-economic opinions may be in line with greats like Marx and Henry George, but he cannot assume the validity of his assumptions just by telling the readership he his resting on such evidence. Several other leading political-economic ideas stand in direct opposition to his conclusions of goverment fixing all health problems to his liking.

All in all, it is hard not to be moved by Farmer's compelling treatment of such horrendous plagues on humanikind. Yet, passion does not always equal pragmatic and working solutions. Therefore, his work will hopefully inspire those who can take his passion to offer clear and viable solutions in the war on these plagues.

Michael Jewell, MPH