AIDS, social inequality and world-systems theory

Louis Proyect lnp3 at
Thu Sep 16 11:51:34 MDT 1999

[From chapter one of Dr. Paul Farmer's new book, "Infections and
Inequalities: the Modern Plagues". Farmer is one of the great thinkers and
humanitarians of our age.]

One learns, I would hope, to discover what is right, what needs to be
righted—through work, through action.


As I prepared this book, an anonymous reviewer of an early draft suggested
that, since the book reflects a personal journey, it should make explicit
the itinerary taken. The idea of a confessional cast to a book about the
plagues of the poor made me shudder, at least initially. But it is
nonetheless true that my experiences in Peru and, especially, in Haiti have
shaped my interpretations every bit as much as has training in anthropology
and medicine.

Curiously, perhaps, I knew early—at twenty years of age, before I went to
Haiti—that I wanted to be a physician-anthropologist. But my experience in
central Haiti helped me decide what kind of medicine to practice. In my
first year there, I witnessed preventable deaths from malaria,
tuberculosis, and postpartum infections. That was enough to make me decide
to specialize in infectious disease. Haiti also strengthened my interest in
social theory, particularly in the relationship between structural
constraints and personal agency. How do life conditions restrict any
individual’s capacity to make choices? The constraint part of the formula
was critical, for poverty was the central fact of life for the Haitians
with whom I lived and worked. It seemed at times as if their every move was
trammeled by the hard surfaces of economic want. "Life for the Haitian
peasant of today," observed anthropologist Jean Weise over twenty-five
years ago, "is abject misery and a rank familiarity with death."

Accordingly, lack of access to effective biomedical services was the most
salient feature of the Haitian health system. The country had only one
medical school, and its graduates usually sought to remain in
Port-au-Prince after graduation—or, better yet, to leave Haiti altogether.
In the decade following the ascent of Dr. François Duvalier to power, for
example, 264 physicians graduated from the state medical school, and all
but 3 left the country. In the eighties, Haiti’s nationwide
physician-to-population ratio was 18 physicians per 100,000 inhabitants,
compared to 250 physicians per 100,000 in the United States—and 364 per
100,000 in neighboring Cuba. This figure varied substantially between the
country’s four administrative districts. The Haitians whose stories are
presented in this book live in the Region Transversale, which is by far the
most underserved region, with about 5 physicians per 100,000 inhabitants.
That made me, from the time I was a medical student, something of a novelty
in rural Haiti.

By the spring of 1984, a year after my arrival, I’d cast my lot with a
group of landless peasants who were working with a dynamic Haitian priest.
He knew nothing about health care, he told me. Since I was going to be a
doctor—he never evinced much interest in my anthropology studies—it would
be my job to oversee health-related projects. So get cracking, he said;
find the necessary resources. Wouldn’t it be better, I objected, to conduct
a preliminary "needs assessment" of the region, one that would ask those
living in the communities to be served what they’d like to see come from
our efforts? "Fine," replied the priest. "Do as you wish. But they’re just
going to tell you they want a hospital."

He was right. Although they also mentioned schools and water and land, most
people surveyed said that a hospital was what the region needed. (Notably,
we never heard requests for research.) Although we knew better than to wait
to hear demands for, say, vaccinations against tetanus and measles, we
decided to act as if we meant it when we insisted that their opinions
mattered to us. At the same time that we sought to establish preventive
services, we built a clinic.

Founded in 1985, the Clinique Bon Sauveur has since served the rural poor
of Haiti’s Central Plateau. My experiences there further shaped medical
interests. Within a year of opening the clinic, we saw our first case of
AIDS, in a young man who presented with disseminated tuberculosis. His
drama became mine too, since no one knew, really, what going on, and I, a
physician-in-training, was often the most "medical" person around. Manno
became a central figure in my dissertation and the book it engendered—and
forced me to come to terms with the nature of my own involvement in the
lives of my "informants." My priority, I knew, was not analytic; it was

>From the early eighties, I commuted between Haiti, with its dearth of
medical services, and Harvard, where there were innumerable doctors and
veritable thickets of hospitals. The experience has been jarring,
certainly, but also illuminating. Haiti became a sort of interpretive grid
what I was hearing in medical school. First, I paid special attention to
formation that would be useful there—and soon became aware of a striking
lack of interest in tuberculosis and parasitology on the part of U.S.
academic medicine. Second, my experience in Haiti made me skeptical of
certain claims of causality. I found precious little discussion of how
poverty affects disease distribution and outcome and virtually no mention
of the pathogenicity of social inequality. Even in social medicine classes,
which did discuss social forces, much of the debate did not ring true for me.

The people I’d been working with in Haiti, hungry and sick, were completely
absent from consideration and so, of course, was their plight. For example,
we heard and read of enormous resources poured into "technological fixes,"
such as neonatal intensive care units, that yielded, view of some, few
discernible results. Critics of the status quo, including many public
health activists, seemed content to call for less funding for these fixes
and more for the interventions of their choice (which were usually
"low-tech" and grounded in preventive medicine).

I knew that Harvard Medical School was merely a brief airplane ride away
from a setting in which markedly unheroic interventions would indeed have
been lifesaving. But didn’t the dilemmas of the Haitian sick call for a
full range of high-tech and low-tech interventions? Why, I wondered
anxiously, was it so manifestly impolitic, in Harvard’s rarefied circles,
to press for the former as well as the latter? Certainly the people of
central Haiti were not specifically requesting low-tech solutions for their
grave medical problems. When asked what they wanted, they had replied
unhesitatingly "A hospital." Not a clinic, a health post, or a dispensary.
Not vaccines or prenatal care. They wanted a hospital.

Although experiences in Haiti made me a fairly discerning consumer of the
literature on medical futility, it slowly became clear that I’d been taken
in by some of the pieties of development work. Talk of "appropriate
technology" and "sustainability" had sounded good to me, at least
initially. The problem was that these sounded silly, even sinister, to the
landless peasants with whom I worked and to many of their staunchest
advocates. Early in my stay in Do Kay, during a year of transformative
experiences, I ran head-on into the fundamental disjuncture between "expert
views" on these matters (as promulgated, for example, in scholarly journals
and in schools of public health) and the views of those whose commitment
was to more radical changes in the circumstances endured by the poor.

Take an exchange between myself and the aforementioned Haitian priest, who
had for decades devoted himself to improving the lot of the rural poor. It
was late 1984, and I had returned to the Central Plateau after months away
in medical school. The priest was anxious to show me the new latrines
they’d built in the village. The latrines were made of cement; they were
solid and square and tin-roofed, and they looked faintly incongruous next
to the thatched and lopsided shacks in which so many of the villagers lived.

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." He wheeled away, fuming, and
refused to speak to me for a couple of days.

With the help of my (sometimes stem) Haitian hosts, I’ve since come to
believe that the hypocrisies of development are not only morally flimsy but
in fact analytically shallow. Many of the positions advanced in the
development field are underpinned by a zero-sum approach: exceedingly
limited funds are available for "sustainable" projects, this logic, and so
those who work for the poor must choose between high-tech interventions and
preventive services. Such Luddite critics of technological advancement
treat poor villages like Do Kay as if were cut off from the rest of the world.

I knew, however, that we were living not in two different worlds but in the
same world. This was brought home repeatedly on an experiential level by
the brevity of my trip back to Miami. More to the point, it brought home on
an analytic level by actually taking the trouble to study the historical
record. The truth was that Do Kay was a squatter settlement of
self-described "water refugees." Their misery had begun, they said when a
U.S.-financed hydroelectric dam, itself the centerpiece of a development
project," flooded the valley where they had farmed for years. The project
had been signed into existence in Washington, D.C.

To better understand the Harvard-Haiti axis, I turned to anthropology.
Although my mentors were mostly engaged, at the time, in symbolic
anthropology, they encouraged me to read widely. I found what’s know
"world-systems theory" to be exceedingly helpful as I attempted to
simultaneously complete medical school and a doctorate in anthropology.
Perhaps less a theory than a call for analytic rigor, the world-systems
approach was a challenge to ferret out connections. Reading the works of
Immanuel Wallerstein, Sidney Mintz, and Eric Wolf was invigorating as I
explored the historical links between Haiti and the United States. In
addition, studying these connections and their construction over wasn’t a
bad way to learn to think about a new epidemic caused by an intracellular
organism. Other illnesses then said to be "emerging" or "reemerging" were
clearly caught up in these same transnational terms. Laurie Garrett, whose
excellent book The Coming Plague contains an ominous forecast, puts it this

"Rapid globalization of human niches requires that human beings everywhere
on the planet go beyond viewing their neighborhoods, provinces, countries,
or hemispheres as the sum total of their personal ecospheres. Microbes, and
their vectors, recognize none of the artificial boundaries erected by human
beings. Theirs is the world of natural limitations: temperature, pH,
ultraviolet light, the presence of vulnerable hosts, and mobile vectors."

AIDS, I learned through research, brought connections, not discontiuities,
into relief. In the midst of this quest for connections, I was becoming
disenchanted with a certain type of disconnected anthropology. This brand
of inquiry had as its goal the search for "thick" local meaning unhinged
from history and political economy. In rural Haiti, nothing much seemed
unhinged from history and political economy; the connections, historically
deep and geographically broad, came into view with minimal effort.

If my experience there estranged me from static cultural analyses, AIDS
drove a final nail in the coffin. When Nancy Scheper-Hughes wrote about
"the mountain of uninspiring social science literature on AIDS, a morass of
repetitive, pious liturgies about stigma, blaming, and difference," I knew
just what she meant. During the years of my training, anthropology joined
the other social sciences in carving out "turf" in the study of AIDS, and
there followed a spate of disconnected studies of "cultural" phenomena
related, in one way or another, to AIDS. Very often, these phenomena were
much more tightly linked to poverty and inequality than to the specific
culture in question—a classic example of the conflation of structural
violence and cultural difference.

What claims did this mountain of literature make? What functions did it
subserve? For what audiences was it written and disseminated? What
canonical concerns framed this inquiry so that certain "cultural" exotica
would be sharply in focus while other considerations—poverty and in-
equality and the feckless, sometimes deadly policies of the powerful—
rarely appeared in the frame of analysis? Work on AIDS and tuberculosis
posed such questions forcefully and often.

I soon learned that scholars trained in different disciplines could examine
the very same topic (the spread of HIV say, or the reason why millions die
of a disease as treatable as tuberculosis) and come up with altogether
incompatible conclusions. What’s more, these scholars could advance such
completely discrepant assessments with great confidence. These "immodest
claims of causality" became one of my central interests, even though such
inquiry was generally viewed as more appropriate to the Sociology of
knowledge than to either anthropology or medicine. To explore these causal
claims, one needed to regard as cultural artifacts not only the popular
press but also the scholarly journals. My doctoral dissertation,
subsequently published as AIDS and Accusation (1992), to be an interpretive
ethnography accountable to history and political economy and informed by a
critical epidemiology. I also tried to tackle many of the
sociology-of-knowledge questions that had arisen as the scientific and
medical communities scrambled to make sense of AIDS.

Immodest claims of causality, the hypocrisies of development, theories
about the origins of AIDS, and other ideologies posing as analysis—all were
run through the interpretive grid that grew out these travels along the
Harvard-Haiti axis. But what sounds like great intellectual adventure was
in fact often painful. A mountain of doctoral dissertations would not, I
suspected, allay the awful suffering I witnessed in Haiti. And things were
going from bad to worse. M services for the people I’d come to care about
were simply not "cost effective" in the increasingly dominant framework of
neoliberalism; were their proposed projects, however modest, sustainable
according to the criteria imposed by the development set that at times
seemed to be running Haiti.

And yet health care for the poor struck me, early on, as the noblest a
physician could have. The unarguable immediacy of their needs, the vitality
of practice of those seeking to meet them, was a rejoinder to both the
uninspiring social science and the ultimately pun policies favored by the
burgeoning development bureaucracies.

Where was I going to work, if I found existing institutions, or at their
confidently advanced ideas, so distasteful? By the time I’d started asking
these questions, I’d struck up with Jim Yong Kim. We shared more or less
the same academic background and the same concerns. What were we to make of
our "ridiculously lavish educations," we who had received so much?

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.
These conduits would have valves that could lead resources to against the
current, back to the poor communities we had studied. was a moral
commitment, certainly, but careful analysis seemed to point to the same
conclusions. Understanding AIDS called for a systemic approach, so why
shouldn’t responses to such diseases be transnational and, given the
transnational nature of HIV’s spread, make a claim on a commensurate share
of the world’s wealth? Business was conducted globally; so was U.S. foreign
policy—often with disastrous results, if outcomes among the poor are deemed
in any way important to an assessment of such policies. Why not medicine?

Jim Kim and I, working largely with friends from outside the academy, felt
sure that our own quest for the vitality of practice needed to be
transnational, rooted in social justice (we followed liberation theology in
making a "preferential option for the poor"), and informed by what we’d
learned at Harvard and in Haiti. We proceeded in precisely this manner,
even though we never assumed, initially, that our projects would matter
much to the academic community that had nourished us so unstintingly. We
were wrong on that score.

Louis Proyect

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