|'Biosocial' Approach to Public Health|
Farmer Warns of Pathogen: Social Inequalities
By Rich McManus
On the Front Page...
Dr. Paul Farmer embodies a number of interesting paradoxes that make him a provocative speaker and a thorn in the conscience of public medicine. Tall, clean-cut and patrician, with a rapid-fire, fact-backed speaking style "Next slide, please" that would certainly have served him well had he elected a career on Wall St., he is as at home in an overcrowded Siberian prison or the slums of Haiti or Lima, Peru, as he is in the halls of Brigham and Women's Hospital in Boston, where he also practices medicine as a Harvard professor. In fact, he says, the people are sometimes friendlier in impoverished rural Haiti than they are in Washington or Geneva, from which he flew in the night before giving a lecture in Masur Auditorium May 24.
Dr. Paul Farmer
The paradoxes don't end with his demeanor and daunting professional milieus; he maintains that despite good intentions, the international public health community's strategy to eradicate multidrug-resistant tuberculosis (MDR-TB) a seeming triumph of compassionate intervention was actually inept, harmful to patients, and only a managerial, as opposed to clinical, success. His insight stems from field work among the world's hardest medical cases, and it often involves having to criticize large bureaucracies that lack his knack for person-to-person care. He speaks with the authority of someone who makes house calls on rag-roofed huts and grimy, far-flung prisons.
Farmer's central interest, to be elaborated in a forthcoming book called Pathologies of Power (the fourth in a series of front-line public health analyses titled in punchy, binary fashion) is discovering "how social inequalities get in the body." Trained in both anthropology and medicine, he studies "what it means to live in a very inegalitarian world." He is indebted, he says, to a number of disciplines and counts as a major insight the existence of a "sociology of knowledge," which recognizes that "all forms of knowledge are socially produced." Drawn to the study of worldwide epidemics (he was a panelist at a 2-day AIDS retrospective given at NIH in fall 1993, decrying the treatment of HIV-positive Haitian detainees at the hands of the U.S. military), he says such outbreaks "are not exclusively biological events. They are also social ones."
Employing a "biosocial" approach to the study of disease, which takes into account "a number of complementary analytic strategies," including molecular biology, political economy, medical anthropology, clinical outcomes and the sociology of knowledge, he examined MDR-TB in two settings: a prison in western Siberia, where he has served as medical director, and an urban slum in Lima, where "TB families" are ostracized and where some families feature as many as eight members with active pulmonary MDR-TB.
In Russia, Farmer found that the rates of imprisonment vaulted from 285 per 100,000 to 700 per 100,000 within just a few years; the elevated detention rate was a major factor in the TB outbreak.
Ironically, TB has surpassed AIDS as the leading infectious cause of death in the world, yet it is completely treatable, he said. Public health experts should have known that drug-resistant strains of tuberculosis would develop and that strategies that could treat them were necessary from the outset. "Very few infectious pathogens do not acquire resistance to the drugs used to treat them."
Farmer was quick to credit the value of basic science, the "enormous yield" of scientific specialization, and the validity of scientific methods and results. He cautioned, however, that "science is a socially constructed phenomenon" and that the choice of research questions and ways of interpreting associated data are "open to the same forces that influence other social affairs."
He took particular issue with a WHO statement in 1997 that "MDR-TB is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible disease."
"That statement was particularly troubling to the young men in Russian prisons and to the families in Peruvian slums," he said, "and happens to be incorrect in both of its assertions."
Farmer warned of "trans-national cases" of MDR-TB, using the case history of a single patient a 50-year-old American relief worker in a Peruvian slum who returned to Boston where he was diagnosed and later died. "Seventy percent of all cases of TB in Massachusetts were diagnosed among foreigners," Farmer reported. "Such trans-national cases are very much not the exception they are increasingly the rule." The migration of pathogens, he said, is common; "It has happened with every major infectious epidemic in the world." He urged trans-national contact-tracing as a containment measure.
Reporting on his trips to a squatters' settlement in northern Lima, Farmer said that active pulmonary MDR-TB is common in local hospitals. More than 450 untreated cases have been found there since 1996, he said. A WHO survey drawing on different methodologies of the same population and era produced no cases. Deadpanned Farmer, "You can find them if you look properly."
Cases tend to be clustered in families, which makes sense given the transmission of MDR-TB by coughs and sneezes. So-called "intrahousehold transmission" is typical. The WHO-imported therapy of DOTS directly observed therapy, short course actually harmed certain patients because its regimen of antibiotics was already outwitted by the disease, so that the treatment was worse than placebo. Cases thought to be "cured" were only temporarily suppressed by the antibiotics.
Farmer further found that capreomycin, a long-forgotten antibiotic that is cidal against TB, is priced far differently, depending upon where in the world you buy it.
Turning lastly to Haiti, where he is medical director of Clinique Bon Sauveur in the town of Cange, Farmer said that TB is rampant among HIV-positive patients; 5,000 of every 100,000 citizens are coinfected. "You can't control TB in countries most affected by HIV," he said, "without taking on HIV as well."
A wide array of conditions contribute to disease in Haiti, including poverty, execrable living conditions, population and economic pressures, gender inequality, patterns of sexual union, and more. "HIV in parts of Haiti is as bad as was predicted years ago, and in some areas worse," Farmer said. Still, he pointed hopefully to a reduction, starting in 1996, of AIDS mortality rates in the U.S., coinciding with the introduction of more effective therapies. New drug combinations have reached even impoverished areas, and Farmer read movingly from a Haitian woman's message to the medical establishment: "What can I say?" wrote a patient who appeared in two slides the first in which she looked ready to die, and the second in which she is beaming heartily "The medicines are eloquent enough."
During a brief Q&A session with the audience, Farmer noted some hopeful trends: the Brigham and Women's Hospital has agreed to create a new division in the department of medicine to examine health inequalities ironically, Farmer and his colleagues will be allowed to see if the health-worker model that was effective in Third World Haiti can be successfully imported to First World Roxbury, Mass.; Farmer thinks NIH is increasingly interested in research proposals that incorporate biosocial principles, and believes that "a new research ethics agenda also requires a biosocial approach, especially when research must be done across steep gradients of social inequality...A lot can be done with better policies and more just distribution of the fruits of science," he concluded.