Disease shines a light on failure

Hugh Pennington reviews a convincing indictment of global health care.

A hallmark of the millennium just gone has been its plagues. It was certainly the first to record them in detail, reflect at length on their impact on the human condition and achieve an understanding of the microbes that cause them. They inspired the emergence of a literary genre that addressed their dramas, tragedies and consequential suffering and wasted lives. Boccaccio, Daniel Defoe, Albert Camus and Thomas Mann make it a distinguished canon. Paul Farmer is a worthy successor.

In his moving and angry book he gives a real-time account of contemporary plagues - Aids and tuberculosis in Haiti and Peru. It is a truly fin de siécle story of unfinished business with an old plague, the fight against a new one, and immorality - immorality because effective remedies are there but are being unreasonably and unfairly denied. Technical incompetents, stiff-necked bureaucrats, hard-hearted capitalists, altruistic priests and starving peasants are all there as well. The only things that distinguish Farmer's account from a Dostoevskian novel is a meed of hard, effective science and a depressingly familiar story of the powerfully malignant effects of racism.

What has gone wrong? Infections and Inequalities is not allegorical or impressionistic or rhetorically overblown in any way. On the contrary, it is an account of things as they are in our own time, reported by an honest professional trained to observe and analyse what he sees as accurately and dispassionately as any person can.

No, his story is one of a persistent and long-standing failure - a failure of public health as a discipline to get its messages across to those who should act on them.

The reasons for this failure are many. Some amount to such powerful excuses that public-health practitioners can almost absolve themselves from blame. Obvious ones are that the benefits of public health may only show themselves in the longer term - certainly longer than electoral cycles - so there are no votes in them. Sick people want to be cured, and prevention, public health's stock in trade, is generally of little interest to most of them. Most doctors see diagnosis and the prescription of remedies as their main business and so they also think that public health is someone else's job. After all, in most countries their income is dependent on attending to individuals, not to the population at large. Even in Britain, the performance indicators that impact on doctors' careers are to do with the care of the sick - such as waiting lists and death rates after surgery - rather than with the prevention of disease. Nobody gets a salary increase if there is a decline in the food-poisoning figures or the infant mortality rate, or is sacked if they go the other way.

Farmer is an American and his book is about the Americas. He is clearly driven to fury and outrage by statistics like the fact that although the United States spends half the entire global expenditure on health, the differences in life expectancy between various communities within its borders are greater than in any other country in the world. But it would be wrong to think that this is a problem restricted to places where the ability to pay determines the kind of health care one receives. We have unacceptably large variations in the indicators of health in Britain as well. Most of the diseases that are responsible are not caused by microbes.But some are.

Just as Farmer describes for Haiti and Peru, we have some diseases that accurately track the fault lines in society and target the deprived and the dispossessed and the marginalised.

Thus colleagues in the department in which I work are right now tracking the spread of a drug-resistant strain of the tubercle bacillus across Scotland and other Celtic nations and investigating a big outbreak of hepatitis B in Aberdeen. The significance of these things is more than that the victims are not middle class. These events should not have happened at all. We have been curing tuberculosis with drugs and

preventing hepatitis B by vaccination for years. Clearly we are failing to do these things properly.

The author makes a similar diagnosis in his book. Although he identifies social inequality as a major determinant of disease, he is adamant that standing back until inequality is remedied, because nothing else will work,is completely wrong.

He says that those who hold that advocating the delivery of high-quality, high-tech care is incompatible with addressing the social roots of disease fall into what he calls the "Luddite trap".

Farmer goes on: "Nothing is wrong with high-tech medicine, except that there isn't enough of it to go around. It is, in fact, concentrated on precisely those areas where it will have the most limited effects. We need more and better clinical services for those marginalised by poverty and by discrimination."

He goes further with his "Luddite" categorisation by including what he calls the morally flimsy, analytically shallow pieties and hypocrisies of development work - "appropriate technology" and "sustainability". "Only limited sums are available for 'sustainable' projects, goes this logic, and so those who work for the poor must chose between, say, high-tech inventions and preventive services." His counterblast - a telling anecdote of a priest in the central plateau of Haiti - is typical of his hard-hitting style and strong examples:

"[He] was anxious to show me the new latrines ...[they] were made of cement ... solid and square and tin-roofed and they looked faintly incongruous next to the thatched and lopsided shacks in which so many ... villagers lived. Unwisely, I asked whether the latrines were really 'appropriate technology' for such a poor village. The priest was furious. 'Do you know what "appropriate technology" means?' he finally answered. 'It means good things for rich people and **** for the poor.'"

Farmer is an anthropologist as well as an infectious disease doctor. He divides his time between Harvard University, Boston's Brigham and Women's Hospital and the Clinique Bon Saveur in central Haiti. This means that his autobiographical account is truly multidisciplinary. As a clinician he brings to his account the lives and deaths of many real people.

It is hard to think of more compelling examples to underpin his arguments.It makes the book and its message accessible to the general reader and forcefully reminds doctors, nurses, scientists, sociologists, economists and aid workers of their unfinished business. As a microbiologist I found his analysis of why disease targets the poor and why they die quicker deeply convincing.

It is inevitable that the book focuses on the deficiencies of American health systems. They are profound. But the main lessons he draws are for us all. We must do all we can to diminish social inequality. But at the same time we must work equally hard to make sure that those benefits of modern medicine proven to be effective are made available to all on the basis of need - not on the ability to pay or on where or how people live. Disease unerringly tracks our failure to do these things.

Hugh Pennington is professor of bacteriology, University of Aberdeen.