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Paul Farmer’s Infections and Inequalities reflects on his experiences since 1984 as a physician at Clinique Bon Sauveur in rural Haiti, dealing primarily with victims of TB and AIDS. In a collection of ten essays, half of which were previously published, Farmer relates personal stories in the voice of the marginalized victims and then adds his own analysis.

The authors in Dying for Growth include political economists, anthropologists, epidemiologists and historians, but the issues they address are prompted by the concerns of doctors and patients. Incorporating the strengths of the personal accounts found in Infections and Inequalities, Dying for Growth adds a macroeconomic perspective of the roles transnational corporations and international financial institutions play in the health of the world’s poorest and sickest.
 
Double standard
 
A palpable anger permeates each paragraph of Farmer’s book and is quite understandable: most of the patients he writes about are now dead of preventable illness.

Farmer lays much of the blame for this tragedy on the double standard that is applied to the health and lives of people in less industrialized countries. Cost-effectiveness is often used as a justification to fund only low-cost, “appropriate technology” interventions for HIV and AIDS. Farmer believes that this argument is unethical and dishonest. Farmer’s Third World colleagues want hospitals, not preventive programs. Instead of needs assessments and studies, they want access to new advances in pharmacotherapy.

He concurs with New England Journal of Medicine editor Marcia Angell that the use of a placebo control group in an African study of HIV treatment is unethical when the prohibitively expensive antiretroviral AZT is already known to be effective in reducing perinatal transmission of the virus. It is reminiscent of the notorious Tuskegee trials in the early part of the 20th century when African-Americans with syphilis were left untreated in order to observe the “natural history” of the disease.

Farmer finds it ironic that those who promote the HIV study say that they could not impose American standards of care on African people, yet they often have no compunction supporting governments and institutions that impose structural adjustments, which have a devastating effect on the poor.

Yet the strength of Infections and Inequalities is not found just in this provocative analysis but in its human stories. For me, these stories read like the tragic novels of Thomas Hardy, where the heroine proceeds to an inevitable – but seemingly avoidable – conclusion.

The system thwarts the valiant efforts of people to overcome obstacles, while simultaneously blaming the victim. Benedicta, a poor TB victim in Peru, is given sanctimonious advice by doctors not to cough on others, to avoid crowded situations, to find clean water and to attend clinics when she cannot even afford bus fare, let alone drug costs. When she finally scrapes together money for treatment but fails to get better, she is considered non-compliant and difficult. The fault instead was systemic. Even though her brother was known to have died of a drug-resistant strain of TB, Benedicta’s doctors persisted with the ineffective, standard treatment.

When all treatment seems futile, with his patients dying around him like flies, and when little seems likely to change at the global level, what allows Farmer to go on each day? The answer may be found in the response of one of his patients: “Doctor, when all around you, liars are the only cocks crowing, telling the truth is a victory.”
 
Economic causes
 
The editors of Dying For Growth agree with World Bank rhetoric that the health situation of the poor would be worse without economic growth, but contend that current strategies designed to ameliorate their situation have hindered more than helped.

The collection offers a historical analysis of labour practices, environmental impacts, the effects of advertising and promotion, and deals thoroughly with transnational corporations. The authors show that corporations have little incentive or inclination to act in the public interest: whether it be pharmaceutical companies ignoring research into diseases affecting the poor, or maquiladoras flouting environmental standards and summarily firing employees who try to organize unions or “threaten productivity” by getting pregnant.

Health and economic situations are examined in Russia, Haiti, Peru, Cuba, El Salvador and India. A chapter on manufacturing practices and marketing of infant formula, cigarettes, pesticides, pharmaceuticals and weapons will be of special interest to environmentalists.

With a wealth of information rarely found in one place, both books should be interesting for specialists such as health professionals, economists, development workers and anthropologists. At the same time they are quite accessible for a general audience, full of anecdotes and examples. Dying for Growth, in particular, is an excellent introduction to trade and development issues, with specific country reports, contacts for activists and a dictionary of economic terms.

Despite the impressive strengths of both works, a few deficiencies need to be addressed. I found the lack of blame attributed to Third World leadership and citizens grating and almost paternalistic. There is a mention of kleptocracies such as Mobutu’s in Zaire but little analysis of the possible impact of this corruption on health and education of the poor. But union irresponsibility, poor government decisions, arms purchases and culture also play a role. And surprisingly, there is little in either book on non-governmental organizations.

Both books largely overlook the impact of war and massive military budgets on people’s health, despite the mass movement of refugees and outbreaks of cholera and other infectious disease and famine in many countries. A chapter on the impact of sanctions, which killed a million and a half people in the last decade in Iraq, might also have been appropriate.
 
Personal edge
 
The books also had a personal impact on me as a family physician.

The stories showing how families on the edge can be driven over it by one medical event in a privatized medical system are heartbreaking. But I was also forced to reassess my views of my own patients. Farmer’s team and their enduring empathy are a shining example at a time when few physicians seem to really care any more for the marginalized of society – those who cause us the major headaches with incessant paper work, chronic unreliability in terms of appointments and non-compliance with treatment regimens.

Doctors must take a broader view of health or risk irrelevance. As Farmer says, “Take physicians. We study vitamin deficiencies, but not land reform. We elaborate protocols to improve standards of care, but rarely discuss equity of access to excellent care and almost never discuss privatization and ‘user fees’. … We learn about patho-physiology, but never the embodiment of the social forces that set in motion a series of events.”
 
Neil Arya is a family physician, adjunct professor in Environmental Studies at the University of Waterloo, and former president of Physicians for Global Survival.