Infectious Inequalities

 

·         renowned global health advocate,

·         medical anthropologist,

·         cofounder of Partners In Health, and

·         chair of the Department of Global Health and Social Medicine at Harvard     Medical School.

·        U.N. Special Adviser to the Secretary-General on Community-based Medicine and Lessons from Haiti.

The most publicly influential anthropologist since Margaret Mead and her mentor, the “founding father” of U.S. anthropology, Franz Boas. 

·         Seeing the world from the perspective of the planet’s poorest. Unlike many doctors (and anthropologists for that matter), Farmer has lived for decades with his patients, first in Haiti and later in communities from Rwanda to impoverished neighborhoods in Boston.

o   “It took me a relatively short time in Haiti,” Farmer writes of the beginnings of his career in his 2003 book Pathologies of Power, “to discover that I could never serve as a dispassionate reporter or chronicler of misery. I am only on the side of the destitute sick and have never sought to represent myself as some sort of neutral party.” 

·         Farmer’s work is unflinchingly committed to social justice, global equity, and the idea that health care is a human right, beginning with what he calls “the most basic right . . . to survive.” Like his medicine, Farmer’s anthropology is thus an anthropology in service to the poor.

o   Importantly, this does not mean an anthropology of the poor. Farmer is well aware that “writing of the plight of the oppressed is not a particularly effective way of assisting them.” After all, anything one might say is likely to be used against them. 

o   Instead, Farmer is interested in studying and exposing the “processes and forces that conspire” to constrain the agency of the poor and that cause poverty, disease, and suffering.  

·      Interest in the root causes of poverty and the diseases has led to his analysis of “structural violence.”

o   Drawing on the work of Norwegian sociologist Johan Galtung, Farmer calls attention to powerful forms of everyday violence, like poverty, hunger, and poor health, that can be just as deadly as the violence of bullets and war but that tends to be caused by social forces, political and economic institutions, and the decisions of policymakers.

§  The root causes of a Haitian contracting HIV/AIDS are to be found not in personal irresponsibility but in the displacement of a village by a dam planned and funded by powerful actors in Washington, D.C.; by the impoverishment the dam created; and by the long-term impoverishment of Haiti through centuries of subjugation at the hands of the United States and European powers dating to the days of slavery.  

·       Farmer’s is a bio-sociocultural-political-economic-historical anthropology.  

o   His work as both an anthropologist and a physician revolves around the lives of individuals suffering amid powerful structural forces. He combines an empathetic understanding of people’s lived experience and how people make meaning in their lives with a political, economic, and historical analysis of the large-scale forces that shape individual lives. Coupled with an appreciation for the biological vectors of disease causation.

·     His tireless commitment to creating positive social change and to using his anthropological and medical skills to help improve the lives of the poor.

o   (When told he should spend more time with his wife and child in Paris, Farmer responded, “But I don’t have any patients there.”)

·         Community based and sustainable health care development.

o   Farmer and Partners In Health, emphasize working in solidarity with those they serve; training Haitians and others to become doctors, nurses, and community health care workers; and building sustainable health care infrastructures designed to be part of public health care systems. 

o   Haitian counterpart organization Zanmi Lasante

§  IMPACT (according to Kidder in Haiti)

·         Zanmi Lasante had built schools and houses and communal sanitation and water systems throughout its catchment area [in central Haiti].

·         Vaccinated all the children

·         Greatly reduced both local malnutrition and infant mortality.

·         launched programs for women’s literacy and for the prevention of AIDS

·         Reduced the rate of HIV transmission from mothers to babies to 4 percent—about half the current rate in the United States.

·         When Haiti had suffered an outbreak of typhoid resistant to the drugs usually used to treat it, Zanmi Lasante had imported an effective but expensive antibiotic, cleaned up the local water supplies, and stopped the outbreak throughout the central plateau.

·         In Haiti, tuberculosis still killed more adults than any other disease, but no one in Zanmi Lasante’s catchment area had died from it since 1988.

·         Partners in Health (PIH) has accomplished far more since its inception.

o   serves some 2.4 million people in 12 countries, in settings that include post-genocide Rwanda, Peruvian slums, and Russia’s prisons.

o   In devastated post-earthquake Haiti, PIH recently inaugurated a 300-bed, state-of-the-art, solar-powered university teaching hospital that represents the country’s largest post-earthquake reconstruction project.  

·         PIH and Farmer reject conventional public health wisdom about what’s “possible” in the provision of health care in impoverished settings.

o   They reject arguments that treatments available in wealthy countries like the United States aren’t “cost effective” in settings like Haiti.

o   Guided by the radical idea that all human lives are equal, that PIH should provide the same quality of care to the poor that the wealthy want for their own family members, that health care is a human right, PIH and Farmer demand nothing less than a “preferential option for the poor.” 

“That goal is nothing less than the refashioning of our world into one in which no one starves, drinks impure water, lives in fear of the powerful and violent, or dies ill and unattended,” Farmer says in a National Public Radio “This I Believe” essay. 

“Of course such a world is a utopia,” Farmer continues, “and most of us know that we live in a dystopia. But all of us carry somewhere within us the belief that moving away from dystopia moves us towards something better and more humane. I still believe this.” 

Emerging Infectious Diseases and the Impact of Inequality

Ebola, TB, and HIV infection are in no way unique in demanding contextualization through social science approaches. These approaches include the grounding of case histories and local epidemics in the larger biosocial systems in which they take shape and demand exploration of social inequalities

• Responsible factors include ecological changes, such as those due to agricultural or economic development or to anomalies in the climate; human demographic changes and behavior; travel and commerce; technology and industry; microbial adaptation and change; and breakdown of public health measures
• human actions have played a large role in enhancing pathogenicity or increasing resistance to antimicrobial agents-the sociogenesis, or anthropogenesis of emerging infections
• Malaria's decline in this country was "due only in small part to measures aimed directly against it, but more to agricultural development and other factors some of which are still not clear" 
• These factors include poverty and social inequalities, which led, increasingly, to differential morbidity with the development of improved housing, land drainage, mosquito repellents, nets, and electric fans—all well beyond the reach of those most at risk for malaria. In fact, many "tropical" diseases predominantly affect the poor; the groups at risk for these diseases are often bounded more by socioeconomic status than by latitude.
• The model of health transitions suggests that nation-states, as they develop, go through predictable epidemiologic transformations. Death due to infectious causes is supplanted by death due to malignancies and to complications of coronary artery disease, which occur at a more advanced age, reflecting progress.
• the concept of national health transitions also masks other realities, including intranational illness and death differentials that are more tightly linked to local inequalities than to nationality.
• In Harlem the death rate due to infectious disease and violence is higher than in Bangladesh
• the health of the individual is best ensured by maintaining or improving the health of the entire community
• But what is Community? The dynamics of emerging infections will not be captured in national analyses any more than the diseases are contained by national boundaries, which are themselves emerging entities—most of the world's nations are, after all, 20th-century creations.

New Questions for the Modern Transnational Reality: 

• What are the mechanisms by which changes in agriculture have led to outbreaks of Argentine and Bolivian hemorrhagic fever, and how might these mechanisms be related to international trade agreements, such as the General Agreement on Tariffs and Trade and the North American Free Trade Agreement? 
• How might institutional racism be related to urban crime and the outbreaks of multidrug-resistant TB in New York prisons? 
• Does the privatization of health services buttress social inequalities, increasing risk for certain infections—and death—among the poor of sub-Saharan Africa and Latin America? 
• How do the colonial histories of Belgium and Germany and the neocolonial histories of France and the United States tie in to genocide and a subsequent epidemic of cholera among Rwandan refugees? 
• Similar questions may be productively posed in regard to many diseases now held to be emerging.

CASES: Ebola, TB, HIV, COVID

EBOLA

The Institute of Medicine lists a single "factor facilitating emergence" for filoviruses: "virus-infected monkeys shipped from developing countries via air"...but:

• the distribution of Ebola outbreaks is tied to regional trade networks and other evolving social systems. 
• impacts people living in poverty, and health care workers who serve the poor, but not others in close physical proximity
• Most expert observers thought that the cases could be traced to failure to follow contact precautions, as well as to improper sterilization of syringes and other paraphernalia, measures that in fact, once taken, terminated the outbreak
• In Zaire, one's likelihood of coming into contact with unsterile syringes is inversely proportional to one's social status. Local élites and sectors of the expatriate community with access to high-quality biomedical services (viz., the European and American communities and not the Rwandan refugees) are unlikely to contract such a disease.
• The changes involved in the disease's visibility are equally embedded in social context. The emergence of Ebola has also been a question of our consciousness. -- print and broadcast media, have been crucial in the construction of Ebola—a minor player, statistically speaking, in Zaire's long list of fatal infections—as an emerging infectious disease

TB

Its recrudescence is often attributed to the advent of HIV—the Institute of Medicine lists "an increase in immunosuppressed populations" as the sole factor facilitating the resurgence of TB, and drug resistance. 

• the most important contributor to this state of ignorance was the greatly reduced clinical and epidemiologic importance of tuberculosis in the wealthy nations"
• TB has not really emerged so much as emerged from the ranks of the poor --one place for diseases to hide is among poor people, especially when the poor are socially and medically segregated from those whose deaths might be considered more important.
• when poor people immigrate into the United States, an increase in TB incidence is inevitable. In a recent study of the disease among foreign-born persons in the United States, immigration is essentially credited with the increased incidence of TB-related disease 
• many persons with TB in the United States live in homeless shelters, correctional facilities, and camps for migrant workers.

• But there is no discussion of poverty or inequality, even though these are, along with war, leading reasons for both the high rates of TB and for immigration to the United States. 

HIV

Suspicion: an epidemic Haitian virus that was brought back to the homosexual population in the United States" 

• This proved incorrect, but not before damage to Haitian tourism had been done. Result: more poverty, a yet steeper slope of inequality and vulnerability to disease, including AIDS. 
• The label "AIDS vector" was also damaging to the million or so Haitians living elsewhere in the Americas and certainly hampered public health efforts among them 
• as regards Haiti and AIDS, these mechanisms of propagation included  --"exoticization" of Haiti, racism, the existence of influential folk models about Haitians and Africans, and the conflation of poverty and cultural difference.
• Critical reexamination of the Caribbean AIDS pandemic showed that the distribution of HIV does not follow national borders, but rather the contours of a transnational socioeconomic order. 
• much of the spread of HIV in the 1970s and 1980s moved along international "fault lines," tracking along steep gradients of inequality, which are also paths of migrant labor and sexual commerce
• Like TB, HIV infection is entrenching itself in the ranks of the poor or otherwise disempowered. 
• Rise in women of color: The means by which confluent social forces, such as gender inequality and poverty, come to be embodied as risk for infection with this emerging pathogen have been neglected in biomedical, epidemiologic, and even social science studies on AIDS.

Standard epidemiology, narrowly focused on individual risk and short on critical theory, will not reveal these deep socioeconomic transformations, nor will it connect them to disease emergence. 

• "Modern epidemiology," observes one of its leading contributors, is "oriented to explaining and quantifying the bobbing of corks on the surface waters, while largely disregarding the stronger undercurrents that determine where, on average, the cluster of corks ends up along the shoreline of risk". 
• Neither will standard journalistic approaches add much: "Amidst a flood of information," notes the chief journalistic chronicler of disease emergence, "analysis and context are evaporating . . . Outbreaks of flesh eating bacteria may command headlines, but local failures to fully vaccinate preschool children garner little attention unless there is an epidemic".

SOCIAL INEQUALITY (questions)

What are the precise mechanisms by which these diseases come to have their effects in some bodies but not in others?

• dearth of attention to the effects of sexism and class differences; studies that examine the conjoint influence of these social forces are virtually nonexistent

TRANSNATIONAL FORCES (questions)

How are diseases spread between populations and can they be understood within national boundaries?

What effects might the interface between two very different types of health care systems have on the rate of advance of an emerging disease? 

What turbulence is introduced when the border in question is between a rich and a poor nation? 

• Almost all diseases held to be emerging—from the increasing number of drug-resistant diseases to the great pandemics of HIV infection and cholera—stand as modern rebukes to the parochialism of this and other public health constructs. 
• Many political borders serve as semipermeable membranes, often quite open to diseases and yet closed to the free movement of cures. Thus may inequalities of access be created or buttressed at borders, even when pathogens cannot be so contained.
• Mexico/USA border: Among the infectious diseases registered at this border are: multi-drug-resistant TB, rabies, dengue, and sexually transmitted diseases including HIV infection (said to be due, in part, to "cross-border use of `red-light' districts").

"Risk Groups" versus "Those at Risk" (does it matter?)

• affect-laden issues—attribution of blame to perceived vectors of infection, identification of scapegoats and victims, the role of stigma—are rarely discussed in academic medicine, although they are manifestly part and parcel of many epidemics.

What and Who Get Funding (and Get Noticed)?

• questions of power and control over funds, must be discussed -- That they are not is more a marker of analytic failures than of editorial standards.
• "Diseases that appear not to threaten the United States directly rarely elicit the political support necessary to maintain control efforts"

"The conquest of infectious diseases" (who are we kidding?) 

• the historical regard has shown us that what was not examined during an epidemic is often as important as what was and that social inequalities were important in the contours of past disease emergence. 
• "The key task for medicine," argued the pioneers Eisenberg and Kleinman, "is not to diminish the role of the biomedical sciences in the theory and practice of medicine but to supplement them with an equal application of the social sciences in order to provide both a more comprehensive understanding of disease and better care of the patient. The problem is not `too much science,' but too narrow a view of the sciences relevant to medicine"