Fwd: [BLACK-LEFT] SACP Speech to COSATU Congress

Louis Proyect lnp3 at SPAMpanix.com
Sun Aug 22 15:05:32 MDT 1999

>What I pointed to was that the old emphasis on the working class as subject
>had been rapidly displaced by a totally negative obsession with plagues
>(real in this case but not a substitute for ideas on changing the world) and
>the need for more repression.

Quite a mouthful. I am not sure how to decipher it since the use of the
passive object always throws me (had been rapidly displaced?--displaced by
who?). As far as a totally negative obsession with plagues is concerned, I
might be missing something but isn't AIDS a class issue for Africa? Doesn't
it entail questions of how health service gets delivered, etc? Which
reminds me of a book I picked up a couple of weeks ago by Paul Farmer, an
anthropologist and physician who wrote the highly acclaimed "The Uses of

The new book is titled "Infections and Inequalities: the modern plagues"
and what I've seen so far is extremely compelling. This is from the

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. In
short, all of the forces that bring a patient to a doctor (or keep a
patient from a doctor), all of the processes leading to sickness and then
to diagnosis and treatment, are related to a series of large-scale social
factors. The diagnostic dilemma, m thinking about the health of
populations, is not so very different from that faced by the anthropologist.

So how might humane and compassionate physicians work such perspectives
into their practice? Many of the finest clinicians I know have neither the
time nor the inclination to consider such large-scale questions. to keep up
with the explosion of medical knowledge and in administrative demands, they
are (or feel) consumed by the task at hand—to see a patient through an
acute illness or to diminish the suffering of the chronically ill. Their
patients might prefer such an approach, I suspect, to the one advanced in
this book; no one who is ill wants the doctor visibly distracted by the
problems of others.

In a utopia, perhaps this would be enough. Others would make sure that
everyone had access to high-quality medical services. Someone else would
enforce standards of care and monitor the forces that generate sickness in
a society. Others would make sure that medical care, broadly conceived, was
designed to promote the full development of each member of society.

Alas, we live in a society that encompasses both Haiti and the United
States. It is a society that includes both Harlem and the Lower East Side
of Manhattan, Paris and Kinshasa, London and Bombay. Further, we live in a
society that is poorly defined by national boundaries. Nowhere is this
dearer than in the case of HIV, as I’ve tried to show in previous work:

"The ties that bind Haiti to urban North America have a historical basis,
and they continue to change. These connections are economic and affective;
they are political and personal. One reason this study of AIDS in rural
Haiti returns again and again to urban Haiti and the United States is that
the boundaries separating them are, at best, blurred. The AIDS pandemic is
a striking reminder that even a village as 'remote' as Do Kay is linked to
a network that includes Port-au-Prince and Brooklyn, voodoo and
chemotherapy, divination and serology, poverty and plenty. Indeed, the
sexual transmission of HIV is as eloquent a testimony as any to the
salience—and complicated intimacy—of these links."

Such arguments are not inappropriate to the analysis of other diseases,
including tuberculosis. Is it mere polemic to argue that in terms of social
causation the coronary artery disease of millions of overfed northerners is
linked to the tuberculosis of malnourished Haitian women?

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. In fact, the spectacular successes of biomedicine have in many
instances further entrenched medical inequalities. This necessarily happens
whenever new and effective therapies—from antituberculosis drugs to
protease inhibitors—are not made readily available to those in need.
Perhaps it was in anticipation of late-twentieth-century technology that
Virchow argued that physicians must be the "natural attorneys of the poor."

In any setting where medical injustice is a given, it is incumbent upon
physicians and other healers to respond to the troubling questions posed by
the destitute sick. These issues cannot be left to the leaders of the
insurance and pharmaceutical industries, whose bottom line is not relief of
suffering. Until doctors ask other types of questions—Who becomes sick and
why? Who becomes a patient? Who has access to adequate services? How might
inequalities of risk and outcome be addressed?—they will remain at least as
blind as the anthropologists who "missed the revolution."

Louis Proyect

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