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 infectious diseases, is a little critical of this view. He writes, “Throughout the world, those least likely to comply are the 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 shantytown Peru. The world view he portrays in the book is shaped by his frontline 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 preoccupation with the exotic nature of cultural differences have caused them to “miss the revolution” or to fail to recognize the pathogenic effects of poverty and inequality, what he calls “structural violence”. He is critical, too of the 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 reveals 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”; no he is not 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 cure is available. The stories used hit home the meaning the author wanted to convey. For me these stories read like any of the classic tragedies written on human suffering. The system applauds the valiant efforts of people who overcome obstacles, while simultaneously blaming the victim.
Benedicta, a poor TB victim in Peru, is given sanctimonious advice by doctors not to cough on others, to avoid crowded situations, to find clean water and to attend clinics when she cannot even afford bus fare, let alone drug costs. When she finally scrapes together money for treatment but fails to get better, she is considered non-compliant and difficult. The fault instead was the systemic. Even though her brother was known to have died of a drug resistant strain of TB, Benedicta’s doctors persisted with the ineffective, standard treatment.
The strength of this book is the combination of the author’s analysis, his 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 vocal with HIV. He speculates that economic structural readjustment programs such as those run 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. Reference: Farmer, P. (2001). Infection and Inequalities. Berkeley: University of California Press.