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.
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