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Infections and Inequalities: The Modern Plagues

Copyright Date: 1999
Edition: 1
Pages: 419
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  • Book Info
    Infections and Inequalities
    Book Description:

    Paul Farmer has battled AIDS in rural Haiti and deadly strains of drug-resistant tuberculosis in the slums of Peru. A physician-anthropologist with more than fifteen years in the field, Farmer writes from the front lines of the war against these modern plagues and shows why, even more than those of history, they target the poor. This "peculiarly modern inequality" that permeates AIDS, TB, malaria, and typhoid in the modern world, and that feeds emerging (or re-emerging) infectious diseases such as Ebola and cholera, is laid bare in Farmer's harrowing stories of sickness and suffering. Challenging the accepted methodologies of epidemiology and international health, he points out that most current explanatory strategies, from "cost-effectiveness" to patient "noncompliance," inevitably lead to blaming the victims. In reality, larger forces, global as well as local, determine why some people are sick and others are shielded from risk. Yet this moving account is far from a hopeless inventory of insoluble problems. Farmer writes of what can be done in the face of seemingly overwhelming odds, by physicians determined to treat those in need. Infections and Inequalities weds meticulous scholarship with a passion for solutions-remedies for the plagues of the poor and the social maladies that have sustained them.

    eISBN: 978-0-520-92708-7
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-viii)
  2. Table of Contents
    (pp. ix-x)
  3. Preface to the Paperback Edition
    (pp. xi-xl)
  4. Acknowledgments
    (pp. xli-xliv)
  5. Introduction
    (pp. 1-17)

    Early on the morning of her death, Annette Jean was feeling well enough to fetch a heavy bucket of water from a spring not far from her family’s hut. In the weeks prior to that day, she had been complaining of a “cold.” It was not serious, she thought, although night sweats and a loss of appetite were beginning to trouble her. Annette’s brothers later recalled that she was cheerful, “normal,” that morning. She made everyone coffee and helped her mother load up the donkey for market. It was an overcast day in October of 1994, and Haiti’s rainy season...

  6. 1 The Vitality of Practice: ON PERSONAL TRAJECTORIES
    (pp. 18-36)

    As I prepared this book, an anonymous reviewer of an early draft suggested that, since the book reflects a personal journey, it should make explicit the itinerary taken. The idea of a confessional cast to a book about the plagues of the poor made me shudder, at least initially. But it is nonetheless true that my experiences in Peru and, especially, in Haiti have shaped my interpretations every bit as much as has training in anthropology and medicine.

    Curiously, perhaps, I knew early—at twenty years of age, before I went to Haiti—that I wanted to be a physician-anthropologist....

  7. 2 Rethinking “Emerging Infectious Diseases”
    (pp. 37-58)

    AIDS. Ebola. Flesh-eating bacteria. With newspaper and television reports rife with references to mysterious and lethal outbreaks caused by new (or newly virulent) pathogens, perhaps it’s safe to conclude that we’re living in a time of unprecedented popular interest in infectious diseases. Yet medical historians might be quick to discern, in this most recent wave of hysteria and genuine interest, but a small peak in that jagged line charting the course of popular concern with epidemic disease.

    That’s not to say that there’s nothing new under the sun. This most recent surge of interest comes at a time when novel...

  8. 3 Invisible Women: CLASS, GENDER, AND HIV
    (pp. 59-93)

    The close of the 1980s found me sitting in a new clinic in a small village in Haiti’s Central Plateau. What awaited us outside in the noisy courtyard was not entirely what we’d expected. Certainly we should have anticipated the crowd, since ours was the first facility in the region to declare a special interest in the destitute sick. And we should have expected that many would be gravely ill by the time they reached our doorstep. Granted, we did expect patients with tuberculosis. But we were nevertheless surprised by just how many rural families were affected by a disease...

    (pp. 94-126)

    Statistics, goes the old saying, are a lot like prisoners: they’ll say anything if you torture them long enough. Although most of this book is based on research conducted in Haiti and Peru, some of it derives from a critical rereading of others’ work, with an eye toward elucidating the role of social inequalities in the distribution of disease and poor outcomes. My first real turn at such a rereading came fifteen years ago, shortly after the first cases of AIDS were identified in Haiti. It was then, I believe, that I set out on a new path, at least...

  10. 5 Culture, Poverty, and HIV Transmission: THE CASE OF RURAL HAITI
    (pp. 127-149)

    The preceding chapter describes some of the important work regarding HIV transmission that has been conducted in urban Haiti over the course of the past fifteen years. Haiti, however, a country of well over seven million inhabitants, is generally considered to be a substantially rural nation,¹ and it is significant that few studies of HIV transmission have been conducted in rural parts of the country. As the ties that link rural and urban Haiti are economically and affectively strong, an understanding of the urban epidemic is a necessary prologue to an investigation of HIV transmission in rural areas, the subject...

  11. Miracles and Misery: AN ETHNOGRAPHIC INTERLUDE
    (pp. 150-157)

    I have worked in the same village in Haiti’s Central Plateau since 1983, and every year since has brought more of the misery and miracles that fuel me and my writing. The misery is everywhere; the miracles are discerned, often, by others. A pair of simple examples will suffice. One is from 1984 and the other from 1996. In the former instance, still a student, I was learning the ropes. I’ve told the story before, erasing myself from the scene in keeping with canonical trends in ethnographic writing:

    In January 1984, Église Saint-André was commandeered as a clinic for residents...

    (pp. 158-183)

    Among the new challenges that AIDS presents to anthropology, some are theoretical and not substantially different from the challenges faced by other ethnographers who seek to study, comprehend, and describe new phenomena. Others involve the ethical dilemmas inherent both in the study of a terrible new affliction for which we have only limited therapeutic recourse and in the deeply vexed question of how anthropologists might best contribute to preventive efforts. What follows is a processual ethnography of the advent of AIDS in the small village of Do Kay. While Chapter 5 focused on the historical and practical dynamics of HIV...

    (pp. 184-210)

    The World Health Organization recently announced that in 1996 alone some three million persons died of tuberculosis.¹ Not since the turn of the century, when tuberculosis was the leading cause of young adult deaths in most U.S. cities, has the disease claimed so many lives. Tuberculosis, we’re told, has returned “with a vengeance.”² In the language of the day, it’s an “emerging infectious disease.” In scientific publications and in the popular press, the refrain is the same: tuberculosis, once vanquished, is now emerging to trouble us once again.

    According to many of the voices echoed in this book, tuberculosis has...

  14. 8 Optimism and Pessimism in Tuberculosis Control: LESSONS FROM RURAL HAITI
    (pp. 211-227)

    A survey of the current literature reveals discordant views on the question of progress in the control of tuberculosis. On the one hand, optimistic observers point with understandable pride to advances in our understanding of mycobacterial pathogenesis and to the elaboration of shorter but more effective treatment regimens. Recent years have seen a growing consensus that even six-month-long, multidrug regimens will lead to high cure rates if therapy is directly observed by medical personnel or health workers. The World Health Organization’s adoption of DOTS—directly observed therapy, short course—has been hailed as a victory by experts from around the...

  15. 9 Immodest Claims of Causality: SOCIAL SCIENTISTS AND THE “NEW” TUBERCULOSIS
    (pp. 228-261)

    René Dubos, who began his career as a distinguished microbiologist but later turned toward the contemplation of the patterns of tuberculosis and other epidemic diseases, underlined the social nature of tuberculosis almost half a century ago: “Tuberculosis is a social disease, and presents problems that transcend the conventional medical approach. . . . Its understanding demands that the impact of social and economic factors on the individual be considered as much as the mechanisms by which tubercle bacilli cause damage to the human body.”¹ Anthropologists and other social scientists have long argued that tuberculosis will not be eradicated without attention...

    (pp. 262-282)

    Suppose that you’re a physician caring for patients infected with HIV. Perhaps your patients are typical of the more than thirty million people living with HIV in the world today.¹ That is, your patients are young—with a mean age of less than thirty years—and have the hopes and dreams of most young people. Half of them are women, most of them raising children. And the clear majority of your patients live in poverty.

    This certainly describes my own patients. Some of them live in a U.S. city; the rest live in rural Haiti. On the one hand, these...

  17. Notes
    (pp. 283-318)
  18. References
    (pp. 319-368)
  19. Index
    (pp. 369-375)
  20. Back Matter
    (pp. 376-376)