ForeWord Reviews

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Partner to the Poor

A Paul Farmer Reader

Foreword Review — July / Aug 2010

When United Nations Special Rapporteur Nigel Rodley visited pre-trial detention centers in Moscow in 1994, he was appalled by what he saw. He would “need the poetic skills of a Dante or the artistic skills of a Bosch adequately to describe the infernal conditions” in the centers, he remarked in his report. Entering one of the cells, he was “hit by a blast of hot, dark, stinking gas that passes for air.” There was “virtually no daylight from covered or barred windows” and “insufficient room for everyone to lie down, sit down, or even stand up at the same time”; detainees were allowed to leave the cell only one hour a day. He noted the “extremely high incidence of tuberculosis” in the centers.

Four years later, when Paul Farmer arrived in Moscow, conditions were still grim. The “sardine-can atmosphere” of prisons and detention centers made it easy for tuberculosis to spread among inmates, many of whom continued to receive treatment with drugs to which the causative organism was resistant. In a tuberculosis penal colony, a facility located a hundred kilometers east of Moscow and designed to house prisoners who were completing their treatment, the medical director blamed her low medication budget for poor cure rates. With less than three dollars to spend for a year’s supply of drugs for each patient, she could not procure the required “second-line” drugs.

Judges do not mention disease when they pronounce sentence, yet for prisoners the infection is part of the sentence. Prisons around the world serve as incubators and amplifiers of infectious disease—in Partner to the Poor, Farmer describes outbreaks of drug-resistant tuberculosis in prisons in the United States. Large numbers of cases have been reported in prisons in African and Central Asian countries. And the organisms do not remain confined within prison walls. Prisoners can infect visitors, guards, and upon release, others. A New York Post journalist contracted tuberculosis while reporting on an outbreak at Rikers Island.

Farmer, who trained as an anthropologist and a physician and specialized in managing infectious diseases, has worked in Haiti since the early 1980s. As he explains to Haun Saussy, the book’s editor, in an interview, “We have been there; we’ve done the work.” This experience allows him to counter the myths that surround the ailments of the poor. He reminds development practitioners, some of whom say it is futile to fight tuberculosis without addressing poverty, that there is “no curative prescription for poverty” yet, as there is for the disease. Other aid officials, including Andrew Natsios, former administrator of the United States Agency for International Development, have resisted offering treatment to AIDS patients in Africa. Natsios told a Congressional committee in 2001 that rural Africans “do not know what watches and clocks are” and, lacking a sense of time, they are incapable of taking their medicines on schedule. However, when researchers reviewed dozens of studies from Africa and North America in 2006, they found that Africans followed AIDS treatment schedules better than North Americans.

Cultural factors, Farmer believes, play a small role in generating and perpetuating disease and suffering among the poor; much of the blame lies with the economic and political arrangements that govern their lives. Aid agencies sometimes worsen their plight by colluding with oppressive regimes. Manno Charlemagne, a Haitian songwriter, draws attention to this connection in his song, “Oganizasyon Mondyal” (“International organizations aren’t for us. They exist to help thieves plunder and steal”).

Farmer writes eloquently about events and issues that are not pressing concerns for most Americans but which are part of an unending tragedy in Haiti and Africa: AIDS, genocide, tuberculosis, and war. When images of misery in distant countries appear repeatedly on television screens, they become hazy for viewers; the suffering of millions turns into a blurred non-event. Partner to the Poor brings the suffering into focus with richly detailed stories of men and women who look for, and often fail to find, jobs and medical care. The book describes Farmer’s early attempts to make sense of their illness narratives through anthropological work in Haiti. Finding that the poor need medicines, not “new studies of their suffering,” he joins hands with community health workers and brings healthcare to communities in Haiti, Peru, and Rwanda. The second half of the book highlights his efforts to reduce the pain inflicted by war and economic inequality.

“Why doesn’t life separate things equally, fifty-fifty?” Charlemagne asks in the song, “Pouki.” Partner to the Poor provides some answers, and as Farmer hopes, may light the “spark of activism” in those who read it.

Karunesh Tuli