Duke University Alumni Magazine

Infections and Inequalities: The Modern Plagues

By Paul Farmer '82. University of California Press, 1999. 375 pages. $29.95.

t is unlikely that most readers of this magazine have had first-hand experience with tuberculosis. After all, it's a disease found in populations whose demographics look quite different from those of an elite institution of higher education. But, before you get complacent, ponder this: By some estimates, nearly one-third of the world's population carries quiescent tuberculosis infection. Think about that the next time you board an international flight.

Paul Farmer's latest book, Infections and Inequalities, is not merely about the threat of a potentially eradicable disease becoming prevalent in Western society. (And anyone who takes only that away from this gripping read has missed the point entirely.) As he has done in his previous work (AIDS and Accusation, The Uses of Haiti and Women, Poverty and AIDS), Farmer, a cultural anthropologist and physician, explores how the currents of history, politics, and socioeconomics come to bear on such pandemics as tuberculosis and AIDS. In so doing, he explores how and why diseases proliferate the ways they do. Interspersing personal and professional anecdotes with hard research, Farmer weaves a persuasive and frightening modern-day horror story that is both sharply analytical and passionately argued.

"Why are some epidemics visible to those who fund research and services while others are invisible?" Farmer asks. "The degree to which [a specific disease] is seen as a threat varies with the degree to which the powerful--or, at least, the non-poor--are deemed to be 'at risk.'"

Farmer is intimately familiar with at-risk populations. As director of the Program in Infectious Disease and Social Change at Harvard Medical School, he divides his clinical time between Boston's Brigham and Women's Hospital and the Clinique Bon Saveur in central Haiti. Through Partners in Health, a nonprofit organization he helped launch in 1987, he has worked with hundreds of thousands of low-income (and no-income) men, women, and children living in Haiti, Peru, Mexico, Honduras, and the inner-city United States.

Farmer's latest book asks pointed questions that reveal systemic prejudices (or worse) inherent in the global medical and health-care arenas. It is dangerous and ultimately irresponsible, he argues, to view an epidemic without taking into account the larger context of social forces at play. If studies show that women at greatest risk for contracting AIDS are fully aware of those risks but choose to ignore them, the question should not be why or whether "educational outreach campaigns" have failed. Rather, what inherent factors in those women's social status, or lack thereof, "conspire to constrain individual agency?" he asks.

When disadvantaged tuberculosis patients abandon protracted treatment regimens, the argument should not be whether it's worthwhile to expend resources treating "non-compliant" patients, or why it's not cost-effective to treat multidrug-resistant tuberculosis in developing countries. Nor is it appropriate to dismiss these patients' decisions as misguided because they seek supplemental cures through more culturally specific (read: non-Western) methods. Instead, Farmer says, we should ask what it is about the access to, or design of, the treatment that makes it ineffective within these specific populations, and therefore more likely for disease to spread.

Take the case of Robert David, a nineteen-year-old Haitian who initially sought treatment for tuberculosis in 1986. For the next decade, David did everything in his power to rid himself of the debilitating disease. After traveling overnight by foot or donkey to the public clinic, he waited all day to be seen. His family sold more than half their land to pay for his drugs, and when they ran out of money, David had no choice but to abandon his regimen. By the time he was finally seen at Farmer's Clinique Bon Saveur, David had developed resistance to the standard course of treatment prescribed for tuberculosis. Farmer and his colleagues arranged for additional medications to be imported. David faithfully followed this course of therapy, despite agonizing side effects, but finally succumbed to his by-then multidrug-resistant tuberculosis.

Should we feel less sympathy for David because he turned to traditional Haitian herbal remedies before consulting a health clinic? Should we scorn David because he abandoned his drug therapy along the way? Or do we focus on the fact that during his nearly decade-long battle with tuberculosis, he endured repeated misdiagnoses of his condition, political upheavals that precluded access to medical personnel and prescriptions (bombed pharmacies, lack of electricity needed to perform clinical tests), and the complete absence of a nationwide tuberculosis detection and treatment campaign?

"Robert David's lamentable experience clearly shows the complicated relationship between individual agency and structural violence," writes Farmer. "In most settings where tuberculosis is prevalent, the degree to which patients are able to comply with treatment regimens is significantly limited by forces that are simply beyond their control."

Infections and Inequalities is geared to the medical profession, certainly, but also to readers interested in cultural anthropology, social justice, and the ethics of health policy. In this moving new work, Farmer makes a persuasive argument for greater compassion and sensitivity to the intractable problems of treating the less fortunate. "I do not wish to exaggerate the power of doctors and other providers; increasingly, it is the pharmaceutical and health-care industries, and also federal governments, who call the shots on questions of access to effective medical care," he writes. "But the power of medicine stems not merely from the wonders of science. It stems, too, from the power of moral suasion. We can call for certain measures not because they are cost-effective--the current and unchallenged mantra --but because they are the best we can do for our patients, especially our poor patients."

--Bridget Booher

Booher '82, A.M. '92 is director of communications for the Hart Leadership Program and the Leadership Initiative at Duke's Terry Sanford Institute of Public Policy.

Guns and Roses

By Taffy Cannon '70, M.A.T. '71. Perseverance Press, 2000. 240 pages. $12.95.

sually when you go on a vacation, you shoot a few rolls of film, buy a souvenir T-shirt, and return to Visa bills. Taffy Cannon, however, takes her vacations wide-eyed, notebook ready, never missing a detail, whether quirky or silly. Tappa, tappa, tappa, clickedy-click, and she produces a topical thriller.

Guns and Roses, Cannon's sixth novel, gives you Colonial Williamsburg as you've never seen it, the vacation from hell. It's a wonderful, witty, entertaining book. Look up "beach read" and you'll find Guns and Roses, the first in a new mystery series.

Former policewoman Roxanne Prescott is Cannon's guide for Irish Eyes' History and Gardens of Virginia Tour. Her seventeen tourist-charges immediately encounter a series of bizarre difficulties and calamities--all clues, mind you, to what lies ahead, dear reader. Dog poop in suitcases, sugar and salt shakers reversed, slippery footing, leeches in the bathroom--and a kidnapped child. Prescott discovers her former skills as a police officer come in handy in the travel business, especially attention to detail and thoroughness. But there is also a difference from her days on the force: "Folks on drugs mainly used Valium and Prozac, and they all had permanent addresses."

As a setting for a murder mystery, Williamsburg has it all. Cannon puts in all the details with her you-are-there descriptive style. The reader soaks up more than Colonial Virginia. Cannon's heroine loves the travel business. We get the insider's view on mother-henning a tour group around, and we are told that "rain is definitely a four-letter word in the travel industry."

Murders aren't bloody, kids don't get terrorized, women don't get violently abused in Guns and Roses. That's not Cannon's style. While the majority of popular mystery authors frequently go over the top, overwriting the mayhem like movie car-chase scenes, Cannon teases the reader with a literate coyness. We know that clue means something, but the puzzle continues to unfold.

Laced with humor throughout, Guns and Roses also injects equal doses of contemporary issues and politics. Indeed, a few paragraphs after her witty aside about the weather, Cannon writes a full page about the Sally Hemmings-Thomas Jefferson liaison.

Cannon is looking for the same success with Roxanne Prescott and her Irish Eyes Travel mysteries that she found with Nan Robinson. An investigator for the State Bar of California, she goes after dirty lawyers. With Robinson leading an investigation, Cannon hit the best-seller mystery charts three times. In A Pocketful of Karma, Tangled Roots, and Class Reunions Are Murder, Cannon created a hard-boiled heroine whom mystery readers, mostly women, could root for and love. Nan and Roxanne share similar strong backbones, a willingness to jump into new situations (and take control of them!), and razor-sharp observation skills. Cannon is no slouch in that arena either.

In her first book, Convictions: A Novel of the Sixties, published in 1985, she used the same structure that worked so well in her later titles, combining story-telling, strong female characters, and a sense of dramatic history. Amid humorous set-ups, the reader got an earful of "the revolution." In Convictions, we follow Prentiss Granger and Laurel Hollingsworth through Duke and beyond. Most journalistic accounts of the Vigil and the evening Allen Building was stormed and tear-gassed can't compare with Cannon's descriptions of the tension, excitement, chaos, and sex as seen through her student heroine's eyes. Fifteen years later, working her plot magic in Guns and Roses, she still manages to add some juicy parts for her mystery fans, involving silk boxer shorts and satin G-strings.

The most fun about Guns and Roses is what attracts most readers to mystery writing: We want to solve the crime, but not too easily, mind you. The author drops a few hints, sends us off on a few wild goose chases, titillates us with tangents. A good mystery writer (and Cannon is one, with this her fourth in the adult mystery genre) plays cunningly with the reader's attention and alertness.

Reading Guns and Roses was like playing a good family game of Clue. Halfway through, I was jumping back pages as if looking for my own notes on the investigation. Even when she was wrapping up her story, Cannon did so with a deftness, keeping the game's tension until the last two pages. The venues, the possible weapons, the characters--I just wished I could have had another turn.

--John Valentine

Valentine '71, M.Ed. '76, co-owner of Durham's Regulator Bookshop, lives in Hillsborough, North Carolina.

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