Quotes from Infections and Inequalities, by Paul Farmer


*work cited
- ‘At best, those of us working in places like Haiti can hope for trickle-down funds if the plagues of the poor are classed as ‘ U.S. security interests.’ (xiii)
- ‘Health education alone does not suffice. In some settings, paradoxically, ‘the presence of health-education materials seemed to lead to lower frequency of condom use.* Notes a recent, candid review: ‘Somewhat surprisingly, towards the end of the second decade of the AIDS pandemic, we still have no good evidence that primary prevention works.’*’ (xxii)
- ‘TB remains, along with AIDS, the leading infectious cause of adult death in the world today.*’ (xxiv)
- ‘It rings hollow to call people to participate in research for the greater good when the poor will rarely benefit from research outcomes.’ (xxv)
- ‘We know that risk of acquiring HIV does not depend on knowledge of how the virus is transmitted, but rather on the freedom to make decisions. Poverty is the great limiting factor of freedom. Indeed, gender inequality and poverty are far more important contributors to HIV risk than is ignorance of modes of transmission or ‘cultural beliefs’ about HIV.* We can already show that many who acquire HIV infection do so in spite of knowing enough information to protect themselves, if indeed cognitive concerns were ever central to preventing HIV among the poor. Until we have effective, female-controlled prevention, whether a microbicide or another, and an effective vaccine, nothing we do should suggest that education can substitute for, or remove the necessity of, effective therapy for AIDS.’ (xxv)
- ‘The struggle for social and economic rights for the poor must become central to every aspect of AIDS research and treatment.’ (xxvi)
- ‘So why is treatment not central to AIDS policy in resource-poor settings? Because we’re told it’s ‘not sustainable’. Why? It costs too much. And why is that? To answer this question, we’d need to look at the manufacture and sale of pharmaceuticals – an industry that, as noted, has consistently had among the highest margins of profit.* ‘The pharmaceutical industry… is extraordinarily privileged. It benefits from publicly funded research, government-granted patents, and large tax breaks, and it reaps lavish profits. For these reasons, and because it makes products of vital importance to public health, it should be accountable not only to its shareholders, but also society at large.*’ ’ (xxvii)
- ‘Why do I feel uncomfortable that researchers from the same institutions dismiss as ‘utopian’ the possibility of treatment for locals who are already sick? How sustainable is that?’ (xxviii)
- ‘The average cost of bringing a new drug to market is approximately $224 million, costs that pharmaceutical companies argue would not be recouped for diseases endemic in poor countries with few resources and no property rights laws to prohibit far cheaper generic products from entering the market.*’ (xxxii)
- ‘Medical statistics will be our standard of measurement: we will weigh life for life and see where the dead lie thicker, among the workers or among the privileged.’ Rudolph Virchow, 1848 (1)
- ‘I had seen a lot of tuberculosis, too, even though the little clinic in Do Kay was built to serve only a tiny region of the Central Plateau. In 1993 alone, we had diagnosed over four hundred cases of tuberculosis, more than were registered in the entire state of Massachusetts that same year. Diagnosing tuberculosis is something I expect to do on a daily basis.’ (2)
- ‘The doctor in me insists that no one should die of tuberculosis today; it’s completely curable.’ (3)
- ‘Exacting its toll among the world’s poor, tuberculosis has ceased to occasion much interest, either in scientific circles or in the popular press. Barry loom puts it even more strongly: tuberculosis, he writes, ‘has been virtually ignored for 20 years and more.*’ ’ (3)
- ‘An estimated three million people each year die of tuberculosis.’ (3)
- ‘… such disparities, which are biological in their expression but are largely socially determined.’ (4)
- ‘Ethnographers usually did little more than mention the terrible infant mortality, miniscule incomes, low life expectancy, inadequate diets, and abysmal health care that remained so routine. To be sure, peasant life was full of joys, expertise, and pleasures. But that figures that led other observers to label Ayacucho region of ‘Fourth world’ poverty would come as a surprise to someone who knew the area only through the ethnography of Isbell, Skar, or Zuidema. They gave us detailed pictures of ceremonial exchanges, Saint’s Day rituals, baptisms, and work parties. Another kind of scene, just as common in the Andes, almost never appeared: a girl with an abscess and no doctor, the woman bleeding to death in childbirth, the couple in their dark house crying over an infant’s sudden death.’* (7)
- ‘Common indeed are the ethnographies in which poverty and inequality, the end result of a long process of impoverishment, are reduced to a form of cultural difference. We were sent to the field to look for different cultures. We saw oppression; it looked, well, different from our comfortable lives in the university; and so we called it ‘culture’. We came, we saw, we misdiagnosed.’ (7)
- ‘Virchow understood, as we his successors have not, that medicine, if it is to improve the health of the public, must attend at one and the same time to its biologic and social underpinnings.’* (10)
- ‘Physicians again need to think hard about poverty and inequality, which influence any population’s morbidity and mortality patterns and determine, especially in a fee-for-service system, who will have access to care… All of the processes leading to sickness and then to diagnosis and treatment, are related to a series of large-scale social factors.’ (10-11)
- ‘Our society ensures that large numbers of people, in the United States and out of it, will be simultaneously put at risk for disease and denied access to care.’ (12)
- ‘Virchow argued that physicians must be the ‘natural attorneys of the poor’.’ (12)
- ‘Studies compiled from the twelfth century onward show that poor, quite simply, are sicker than the nonpoor and that this is true in both rich and poor countries.’* (12)
- ‘We can show that tuberculosis outcomes can be as good working among the rural Haitian poor as they are anywhere else.* Others working in U.S. inner cities have shown that inequalities of survival among those living with HIV can also be erased if high-quality AIDS care is afforded to all, regardless of ability to pay.’ (15)
- ‘One learns, I would hope, to discover what is right, what needs to be righted – through work, through action.’ Daniel Berrigan (18)
- ‘Although [the Haitian peasants] also mentioned school and water and land, most people surveyed said that a hospital was what the region needed.’ (19)
- ‘Unwisely, I asked whether the latrines were really ‘appropriate technology’ for such a poor village. The priest was furious. ‘Do you know what ‘appropriate technology’ means?’ he finally answered. ‘It means good things for rich people and shit for the poor.’ ’ (21)
- ‘Staying put in Boston was not an option, not after all we’d seen. World-systems theory, perhaps, helped us to see people like ourselves, with one foot in Harvard and another in Haiti , as possible conduits for resources.’ (24)
- ‘Many ‘tropical’ diseases predominantly afflict the poor; the groups at risk for the diseases are often bounded more by socioeconomic status than by latitude… this aspect of disease emergence is thus obscured by an uncritical use of the term ‘tropical medicine’, which implies a geographic rather than a social topography.’* (41)
- ‘The ‘health transitions’ model suggests that nation-states, as they develop, go through predictable epidemiologic transformations. Death due to infectious causes is gradually supplanted by death due to malignancies and complications of coronary artery disease; the latter deaths occur at a more advanced age, reflecting progress.’ (41-42)
- ‘A very different picture emerges, however, when we compare causes of death among the wealthiest fifth of the world’s population to the afflictions that kill the poorest fifth: although only 8 percent of deaths among the world’s wealthiest were caused by infections or by maternal and perinatal mortality, fully 56 percent of all deaths among the poorest were caused by pathologies.’* (42)
- ‘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 the paths of labor migration and sexual commerce.’* (50)
- ‘A ‘cure’, though eminently desirable, will not change the prognosis for the vast majority of AIDS sufferers. The advent of more effective antiviral agents promises to heighten those disparities even further: a three-drug regimen including a protease inhibitor costs $12,000 to $16,000 a year.’* (52)
- ‘Diseases that appear not to threaten the United States directly rarely elicit the political support necessary to maintain control efforts.’* (57)
- ‘AIDS is the leading cause of death among African American women ages 25 to 44.’* (77)
- ‘Condoms are a classic case in point. Most U.S. women at high risk of HIV infection are already aware that condoms can prevent transmission, but many of these women are unable to insist that condoms be used because their precarious situations often force poor women to rely on men.’ (84)
- ‘Needle-exchange efforts can decrease the incidence of new infections even in the absence of adequate drug treatment.’* (90)
- ‘Endeavors focused on AIDS, though crucial, must be linked to efforts to empower poor women. The much-abused term ‘empower’ is not meant vaguely here; empowerment is not a matter of self-esteem or even of parliamentary representation. Those choosing to make common cause with poor women must help them gain control over their own lives. Control of lives is related to control of land, systems of production, and the formal political and legal structures in which lives are enmeshed.’ (91)
- ‘HIV is more efficiently transmitted from men to women than vice versa. Some are intuitive: HIV is concentrated in seminal fluid but often difficult to isolate in vaginal secretions. In addition, in comparing male ejaculate to vaginal secretions, inoculum size of course differs by several orders of magnitude. Data from the United States also suggest that HIV is inefficiently transmitted from women to men: in two studies of women whose date of transfusion-associated HIV infection could be ascertained, from 0 to 7 percent of their spouses or regular sexual partners showed evidence of HIV infection.’* (113)
- ‘Originally a region of diverse cultures and economies operating within the framework of several imperial systems, the West Atlantic region has emerged over the centuries as a single environment in which the dualistic United States center is asymmetrically linked to dualistic peripheral units. Unlike other peripheral systems of states – those of the Pacific, for example – the West Atlantic periphery has become more and more uniform, under the direct and immediate influence of its powerful northern neighbors, in cultural, political, and economic terms.’* (124)
- ‘The five countries linked most closely to the United States in 1977 and 1983… are precisely those with the largest number of AIDS cases.’* (125)
- ‘Truck drivers and soldiers have served as a ‘bridge’ from the city to the rural population, just as North American tourists seemed to have served as a bridge to the urban Haitian population.’ (135)
- ‘An examination of [Haitian] forces can serve to inform understandings of the dynamics of HIV transmission in other parts of Latin America and also in areas of Asia and Africa where prevalence rates in rural regions are currently low.’ (137)
- ‘The ability of young women to protect themselves from [HIV] infection becomes a direct function of power relations between men and women.’* (141)
- ‘The forces underpinning the spread of HIV to rural Haiti are as economic and political as they are cultural, and poverty and inequality seem to underlie all of them… international conferences on AIDS have repeatedly neglected this subject.’ (146-147)
- Farmer calls for: ‘investigating the precise mechanisms by which such forces as racism, gender inequality, poverty, war, migration, colonial heritage, coups d’etat, and even structural-adjustment programs become embodied as increased risk.’ (148)
- ‘The myths and mystifications that surround AIDS and slow AIDS research often serve powerful interests. If, in Haiti and in parts of Africa, economic policies (for example, structural-adjustment programs) and political upheaval are somehow related to HIV transmission, who benefits when attention is focused largely on ‘unruly sexuality’ or alleged ‘promiscuity’?’ (149)
- ‘In 1995, more people died of TB than in any other year in history. At least thirty million people will die from tuberculosis in the next ten years if current trends continue. Millions more will watch helplessly as friends and family members waste away, racked with coughing and sweating fever. They may wish that medical science could cure this terrible disease. The truth is, medical science can. Since 1952, the world has had effective and powerful drugs that could make every single TB patient well again.’ WHO, 1996 (184)
- ‘Proje Veye Sante [Partners in Health]... included financial aid and regular visits from community health workers… was designed for poor and hungry people with tuberculosis who receive shabby treatment wherever they go.’ (189)
- ‘By 1992, the situation in New York City looked bleak. The number of cases of tuberculosis had nearly tripled in 15 years. In central Harlem, the case rate of 222 per 100,000 people exceeded that of many Third World countries. Outbreaks of multidrug-resistant tuberculosis had been documented in more than half a dozen hospitals, with case fatality rates greater than 80 percent, and health care workers were becoming ill and dying of this disease.’* (198)
- ‘Although tuberculosis is inextricably tied to poverty and inequality, experience shows that modest interventions have effected dramatic changes in outcome. Pragmatic solidarity means increased funding for tuberculosis control and treatment. It means making therapy available in a systematic and committed way… cure rates could increase from under 50 percent to nearly 100 percent if comprehensive supports, including financial and nutritional aid, are put in place while patients are being treated.’* (207-208)
- ‘If it is true, as Feldberg argues, that ‘scientific professionalism… fundamentally eroded the therapeutic impulse to social reform,’* surely it would be an error to divorce efforts to confront tuberculosis from broader efforts to confront social misery.’ (209)
- ‘Those who remain committed to addressing tuberculosis by championing increased access to effective drugs must resist restricting their field of analysis to the tuberculosis problem. We are told to choose, in Haiti and in much of Africa, between treating tuberculosis and treating malnutrition… Calls for more ambitious interventions are trumped by a peculiarly bounded utilitarianism: such interventions, we’re told, are not ‘cost-effective.’ ’ (209)
- ‘According to a baseline projection, tuberculosis will be the fourth leading cause of death overall in developing countries by the year 2020. Tuberculosis and HIV, which both afflict young adults disproportionately, are the only infections diseases expected to cause more life years to be lost in 2020 than they cause now.’* (212)
- ‘Interest in tuberculosis is at an all-time low, which is certainly striking if deaths are at an all-time high.’ (213)
- ‘ Haiti is Latin America’s oldest nation, having declared itself independent from France after a slave revolt that began in 1791. Haiti had been France ’s most valuable possession; by 1789 the country was producing more wealth than all thirteen North American colonies combined.’ (213-214)
- ‘Since it was founded in 1984, Proje Veye Sante, the small community health program introduced in Chapter 5, has sought to serve the landless peasants and children of the Peligre basic of Haiti’s Central Plateau. In recent years, the project has grown considerably as more villages seek to participate by sending community members to be trained as health workers. Although the project is centered around a large clinic staffed by myself and four other physicians (the Clinique Bon Sauveur), it is in the outlying villages that much of the work takes place: more than fifty village health workers form the backbone of Proje Veye Sante. All paid staff positions are filled by Haitians, most of them natives of the region.’* (217)
- ‘… activities sponsored by Proje Veye Sante such as women’s health initiatives, vaccination campaigns, water protection efforts, and adult literacy groups. These interventions, implemented by community health workers, had proven to be a powerful means of addressing malnutrition, diarrheal disease, measles, neonatal tetanus, malaria, and typhoid fever. Through the community activities, the health workers were able to identify the sick and refer them to the clinic, where, of note, all antituberculosis medications were free of charge.’ (218)
- ‘The new program was designed to be aggressive and community-based, relying heavily on community health workers for close follow-up. It was also designed to respond to patients’ appeals for nutritional assistance. All residents of Sector 1 diagnosed with pulmonary or extrapulmonary tuberculosis would be eligible to participate in a treatment program featuring – during the first month following diagnosis – daily visits from their village health worker. These patients would receive financial aid of $30 per month for the first three months and would also be eligible for nutritional supplements. Further, these patients were to receive a monthly reminder from their village health worker to attend clinic. ‘Travel expenses’ (for example, renting a donkey) would be defrayed with a $5 honorarium upon attending.’ (219)
- ‘Projects designed to treat tuberculosis among the very poor must include financial and nutritional assistance, for many of these patients develop reactivation tuberculosis in the setting of malnutrition or concurrent disease… Second, projects designed to prevent tuberculosis among the very poor must keep in mind a central maxim of tuberculosis control: treatment if prevention… identification and complete treatment of patients with active pulmonary tuberculosis should be the top priority of tuberculosis control in settings like rural Haiti .’ (224)
- ‘Our experience in Haiti suggests that, even more unfortunately, the term [noncompliance] exaggerates patient agency, suggesting that all patients possess the ability to comply.’ (226)
- ‘All too often, the notion of patient noncompliance is used as a means of explaining away program failure. Patient-dependent failure should be a ‘diagnosis of exclusion’ – invoked only after poor program design and lack of access are excluded.’ (227)
- ‘In spite of the theoretical risk to the ‘general population,’ the majority of U.S. cases to date have, again, been registered among the inner-city poor, with significant outbreaks confined to prisons, homeless shelters, and public hospitals.’ (231)
- ‘If tuberculosis control is to be governed by the gurus of cost-effectiveness, it is easy to show that the most serious costs are incurred when we fail to diagnose and treat MDRTB.’ (unknown)
- ‘It has frequently been observed in conferences if not in print, that by treating drug-susceptible disease, it is possible to stem outbreaks of MDRTB. This is false. It is true, however, that better treatment of drug-susceptible disease is likely to decrease the incidence of resistance acquired during therapy.’ (244-245)
- ‘Studies take it as a matter of faith that educational interventions will have significant effects on rates of tuberculosis in a particular population. No one, as far as I know, has ever shown this to be true.’ (255)
- ‘Are you unaware that vast numbers of your fellow men suffer or perish from need of the things that you have to excess, and that you required the explicit and unanimous consent of the whole human race for you to appropriate from the common subsistence anything besides that required for your own?’ Rousseau, 1755 (262)
- ‘Opposition to the aggressive treatment of MDRTB in developing countries may be justified as ‘sensible’ or ‘pragmatic’, but as a policy it is tantamount to the differential valuation of human life, for those who advocate such a policy, regardless of their nationality, would never accept such a death sentence themselves.’ (278)
- ‘It is manifestly contrary to the law of nature that a handful of men should gorge themselves with superfluities while the starving multitude goes in want of necessities.’ Rousseau, 1755 (280)
- ‘The poor, we’re told, will always be with us. If this is so, then infectious diseases will be, too – the plagues that the rich, in vain, attempt to keep at bay.’
- ‘The often linear relationship between poverty and sickness changes as basic nutritional and sanitary needs are met.’ (285)

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