Infections and Inequalities: The Modern Plagues by Paul Farmer (review)

Infections and Inequalities: The Modem Plagues Paul Farmer University of California Press Reviewed by T e rry Simmons Center for Global Policy Studies F o rtun ately, in the United States and Canada medical care is af­ fordable for the insured, and is generally accessible for everyone. Readers of this journal probably can afford to be seriously ill or in­ jured, if their employer provides adequate medical insurance or if they can pay the premiums themselves. Moreover, they probably have sufficient social skills and education to interact successfully with medical personnel and institutions. Still, after a minor accident in any town or city within the territory of the Association of Pacific Coast Geographers, an ambulance ride to the hospital costs more than the annual per-capita income of Haiti. The subsequent hospital emergency-room visit might cost more than the annual per-capita income of Peru. Notwithstanding many well-known public policy and practical issues, North Americans live well and long and are protected competently by sophisticated modern medicine, sanita­ tion, and public health infrastructures. Nevertheless, North Americans still are vulnerable to and play host to tuberculosis, HIV/ AIDS, and other well-known chronic dis­ eases. The specter of bubonic plague—the infamous villain of the Black Death—is as close as infected chipmunks in the Sierra Ne­ vada. Certainly, nineteenth-century diseases such as malaria, typhus, and cholera await their returns to North America when modem sani­ tation and public health infrastructures falter. Meanwhile, new, drug-resistant strains of tuberculosis as well as more exotic tropical diseases such as ebola can threaten North America whenever the next infected passenger disembarks from a Boeing 747 from Asia, Africa, or Latin America. The Four Horsemen of the Apocalypse wait impatiently always. 155 156 APCG YEARBOOK •Volume 62 • 2000 Infections and Inequalities is a challenging, scholarly protest of the social inequalities reflected in the global realities of HIV/AIDS, tu­ berculosis, malaria, typhoid, and other infectious diseases. Infections and Inequalities is a physician's professional biography, and an anthropologist's critical and self-critical analysis of social, economic, and institutional responses of poor Haitian farmers to medical care for tuberculosis and HIV/AIDS. "The book examines the inequali­ ties in the distribution and outcome of infectious diseases. It asks why people...are likely to die of infections such as tuberculosis and AIDS and malaria while others are spared this risk. It explores the creation and maintenance of such disparities, which are biological in their expression but are largely socially determined. This book also explores social responses to infectious diseases, responses rang­ ing from quarantine to accusations of sorcery" (p. 4). Infections and Inequalities provides a theoretical basis for coping with the stark, devastating realities of epidemic diseases and for understanding a global setting where medical knowledge exists but available re­ sources are scarce. Paul Farmer, a physician, medical anthropologist, and director of Harvard Medical School's Program in Infectious Disease and So­ cial Change, examines his personal clinical experience and anthropological fieldwork on the Central Plateau of Haiti since 1983, for which he is well known for AIDS research. He evaluates and reports on clinical experiences in the poor suburbs of Lima, Peru, and in the poor districts of New York City and Boston. Paul Farmer the clinician challenges the reader in practical and ethical terms. At the same time, Farmer the medical anthropologist challenges the reader to reach better theoretical understandings of poor Haitian and Peruvian patients, who suffer and die from infectious diseases. The global HIV/AIDS pandemic, the tuberculosis pandemic, and the threatened pandemic of multidrug-resistant tuberculosis (MDRTB) are quite real. As transnational microbial traffic and in­ ternational capital and commerce travel together, "we discern the pernicious effects of the two-worlds myth" (p. 34). Beyond the frus­ Sim m o n s : Review o f Infections and Inequalities 157 trations of individual medical care, issues of poverty, inequality, and access to care in the developing world may metamorphose into medical emergencies in the developed world anytime an airplane lands or a ship docks. Farmer's medical anthropology shares much with medical ge­ ography. Among geographers, only the late Peter Gould is cited for his The Slow Plague...