Take tuberculosis, with its persistence in poor countries and its resurgence among the poor of many industrialized nations. We cannot understand its markedly patterned occurrence - in the United States, for example, afflicting those in homeless shelters and in prison - without understanding how social forces, ranging from political violence to racism, come to be embodied as individual pathology.
Initially, poverty and racism increase the likelihood that one will become infected with Mycobacterium tuberculosis. The mechanisms by which this occurs include the prevalence of the disease among the poor and the fact that the poor are more likely to live together, often in the cramped, airless quarters that once characterized the 'lung blocks' of industrialized cities and now describe the urban ghettoes in which tuberculosis is endemic. Various institutions designed to serve or contain the poor have in many instances been the settings for amplified outbreaks of tuberculosis. Nardell and Brickner argue, for example, that homeless shelters have become the lung blocks of the late twentieth century. Poverty and racism surely increase the likelihood that one will end up in a shelter, just as these forces arrange the chances that one will wake up in a crack house or a prison.
Once infected, the poor are more likely to progress to active disease. Again, the mechanisms are myriad. Cell-mediated immunity, which keeps tuberculosis quiescent in most persons, may be compromised by malnutrition, HIV infection (or other concurrent disease), or addiction to drugs or alcohol. Addiction, in turn, is usually not comprehensible without an understanding of subjugation and racism, at least not if historical and population-based studies are to be believed. Even reinfection with M. tuberculosis might play a role in ensuring that tuberculosis infection will progress to disease; the risk of reinfection is strongly influenced by the social factors just described.
These same factors determine outcomes among those with active tuberculosis disease. Poverty and racism increase the likelihood of dire outcomes among the sick by restricting access to effective therapy or rendering it less effective if patients are malnourished or addicted. Poverty clearly decreases the ability of patients to 'comply' with demanding, lengthy regimens. Indeed, the advent of truly effective therapies only brings into starker relief the centrality of social inequalities, when unequal access to these therapies heightens the inequalities of infection and reactivation already described.
Thus do fundamentally social forces and processes come to be embodied as biological events."
- Paul Farmer, Infections and Inequalities
So really all of March is TB awareness month. It must be markedly obvious at this point what book I am currently reading (although I'm also embedded in The Bottom Billion, which takes me back to my IR days, and I was reading Reporting from Ramallah, but sadly I think I left it in Trinidad). I love this passage in particular because of the clear and concise way in which Farmer outlines some of the mechanisms by which social forces impact biological realities. An understanding of these mechanisms is essential for anyone who hopes to alter others' medical outcomes.
These pictures (from the same street on which the clinic is located) illustrate a bit of what Farmer is talking about:
Contra el hambre y la pobreza.
Against hunger and poverty.
No hay síndico aquí.
There is no mayor here.
(an arrow points to the ground below)
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