CityReads | Infections and Inequalities

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Infections and Inequalities

Inequality itself becomes a pathogenic force.

Paul Farmer, 1999. Infections and Inequalities: The Modern Plagues, University of California Press.

Sources: https://www.gatesnotes.com/Health/4-Good-Disease-Books

Marmot,M. (1999)Book Review Infections and Inequalities: The modern plagues By Paul Farmer, Nature Medicine volume 5, page727

Martensen, R. L. (2000). Book Review Infections and Inequalities: The modern plagues By Paul Farmer. 389 pp. Berkeley, University of California Press, 1999. $29.95. 0-520-21544-3. New England Journal of Medicine, 342(18)

Tuberculosis (TB) used to be incurable. Today TB is still the number one cause of death from an infectious disease. It has inspired great science, medicine and literature. Think of Dostoevsky, the Bronte sisters, Keats, Lord Byron, Henry James and Thomas Mann. Think of those towering works and figures of literature, and be misled. They show the well-to-do dying of tuberculosis. They did, but tuberculosis always affected the poor more than the rich. In the 1830s, English mortuary registers revealed that“the proportion of consumptive cases in gentlemen, tradesmen, and laborers was 16, 28, and 30% respectively.

What causes tuberculosis in humans? In the late 19^th 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 and currently is the chair of the Department of Global Health and Social Medicine at Harvard Medical School, uses these disciplines and his medical experience in Haiti to provide a trenchant analysis of the biologic and social realities of chronic infectious disease. Farmer co-founded a system of health clinics in Haiti that reaches more than a million people in some of that country’s hardest-to-reach places. Bill Gates listed Infections and Inequalities as one of the Good disease books and recommended it to people.

Structure of Infections and Inequalities

This book consists of ten chapters. The first chapter is the story of an expanding group of people— some of them chroniclers of the modern plagues, others absorbed in combating them. Chapter 2 takes a closer look at the concept of “emerging infectious diseases” and in so doing elaborates the analytic framework used in the rest of the book. The general argument it presents is that social inequalities often determine both the distribution of modern plagues and clinical outcomes among the afflicted. Thus does inequality itself become a pathogenic force.

Subsequent chapters seek to apply this framework to specific diseases—primarily AIDS and tuberculosis— and specific settings. All of the chapters tell the stories of people afflicted by these plagues. In examining these deadly epidemics, the chapters move from a broad sociology-of-knowledge approach to an in-depth look at the dynamics of infectious disease and, finally, to pragmatic interventions designed to improve outcomes. For the events and processes and pathologies chronicled here, biological though they may be, are all of fundamentally social origin. They are biosocial.

Chapter 10, the book’s conclusion, is as much a warning as a plea. The further entrenchment of social inequality has dire implications in a time of rapid advancement in science and technology. the plagues of our times require as “co-factors” such inequalities—that is, steep grades of inequality fuel the persistence or emergence of epidemic disease.

The pathogenic effects of poverty and inequality

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.

Strikingly patterned outbreaks of HIV, tuberculosis, and even Ebola—and the social responses to these outbreaks—all suggest that models of disease emergence need to be dynamic, systemic, and critical. They need to be critical of facile claims of causality, particularly those that scant the pathogenic roles of social inequalities.

Critical perspectives on emerging infections must ask how large-scale social forces come to have their effects on unequally positioned individuals in increasingly interconnected populations. Farmer calls the pathogenic effects of poverty and inequality as“structural violence.”

Disease emergence is a socially produced phenomenon, few have examined the contribution of specific social inequalities. Yet such inequalities have powerfully sculpted not only the distribution of infectious diseases but also the course of health outcomes among the afflicted. The inequalities of outcome are biological reflections of social fault lines.

Poverty and inequality influence any population’s morbidity and mortality patterns and determine, especially in a fee-for-service system, who will have access to care: Who becomes sick and why? Who becomes a patient? Who has access to adequate services? How might inequalities of risk and outcome be addressed?

Poverty and other social inequalities come to alter disease distribution and sickness trajectories through innumerable and complicated mechanisms. Fundamentally social forces and processes do come to be embodied as biological events.

Inequality itself constitutes our modern plague. The burdens of inequality are primarily borne by the poor and marginalized.

To recap, modern inequalities are both local and global. One of the central arguments of Infections and Inequalities is that a lack of systemic and critical analysis permits these global ties to be obscured. And yet new kinds of proximity make inequality, and the plagues that accompany it, very modern affairs. As the book’s subtitle suggests, these sicknesses and inequalities are themselves best thought of as together constituting our modern plagues. Farmer calls attention to the larger forces and processes that determine why some people are sick while others are shielded from risk.

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