The Consumption of the Poor:
Tuberculosis in the Late Twentieth Century
by Paul Farmer

(Excerpted from Infections and Inequalities, 1999)

The Role of Pragmatic Solidarity

At the close of the twentieth century, we are challenged not only to explain the uneven distribution of tuberculosis but also to explain poor therapeutic outcomes in a time when effective treatments have existed for decades. Between 1943, when Selman Waksman and co-workers discovered streptomycin, and the late 1970s, over a dozen drugs with demonstrable effectiveness against tuberculosis were developed. New diagnostic methods, including immune-fluorescence staining and new culture methods, are equally impressive. In fact, in 1997 the FDA approved a test that can identify and amplify mycobacterial gene sequences in a matter of minutes. Now in the pipeline are tools that might identify resistant strains in less than twenty-four hours. We indeed have the scientific knowledge-but the hard truth is that the "we" in question does not include the vast majority of the three million people who died from tuberculosis in 1996. We must acknowledge that our guilt surpasses that of earlier generations, who lacked our resources: Michael Iseman, one of the world's leading authorities on tuberculosis, is right to use the word "shameful" in describing our failure to touch tuberculosis prevalence in much of the world.

Looking toward the next millennium, it is difficult to be optimistic. The arrival of strains of M. tuberculosis that are resistant to all first-line and many second-line drugs is surely a harbinger of pan-resistant strains to come. And HIV looms: ever-increasing numbers of co-infected individuals, most of them poor, promise millions of cases of reactivation tuberculosis. These "excess cases" will in turn infect tens of millions. In failing to curb tuberculosis before the advent of these truly novel problems, it seems clear that a window of opportunity has slammed shut.

Although tuberculosis is inextricably tied to poverty and inequality, experience shows that modest interventions have effected dramatic changes in outcome. Pragmatic solidarity means increased funding for tuberculosis control and treatment. It means making therapy available in a systematic and committed way. For example, we now know that short-course, multidrug regimens can lead to excellent outcomes in even the most miserable settings. In rural Haiti, we learned that cure rates could increase from under 50 percent to nearly 100 percent if comprehensive supports, including financial and nutritional aid, are put in place while patients are being treated.

In San Francisco, one project addressed poor attendance at tuberculosis clinics by moving the clinics to the times and places desired by the patients and replacing staff who placed the blame for poor outcomes on the patients. In New York, where the chances of compliance among injection drug users with tuberculosis were wearily dismissed as hopeless, one clinic more than trebled rates of completion. Much of the success was due to directly observed therapy, but a comprehensive, convenient, and user-friendly approach clearly had an impact too. Especially critical-and important to underline when confronted with claims that treating susceptible disease will somehow make MDRTB go away-were efforts in New York to speed the rate at which resistant strains were identified and then treated with the antibiotics to which they had demonstrated susceptibility.

Pragmatic solidarity means preventing the emergence of drug resistance whenever possible, but it also means treating people like Corina Valdivia. As this book goes to press, a massive pandemic of MDRTB in Russia and other countries of the former Soviet Union becomes even more massive-with minimal public comment and even less public action. Problems of this dimension call for public subsidies of costly second-line drugs as well as for the development of new drugs. "No new antituberculous compounds have been developed by the pharmaceutical industry since the 1970s," observed Cole and Telenti in 1995, although researchers have serendipitously found certain antibiotics that have activity against M. tuberculosis. Reichman sounds a pessimistic note: "Most of the drug companies that publicly announced a quest for TB drugs at the time of the recent resurgence have been noticeably quiet. Few have even shown interest in developing such drugs."

In identifying the microbiological cause of consumption, Koch had hoped to end the era in which tuberculosis could be addressed only "by relief of distress." But tuberculosis remains, at this writing, "the outcome of social misery." If it is true, as Feldberg argues, that "scientific professionalism...fundamentally eroded the therapeutic impulse to social reform," surely it would be an error to divorce efforts to confront tuberculosis from broader efforts to confront social misery. We still have something to learn from the analysis of those who did hot have our tools at their disposal. In 1923, pathologist Allen Krause made this observation: "More or less poverty in a community will mean more or less tuberculosis, so will more or less crowding and improper housing, more or less unhygienic occupations and industry." This statement remains as true today as it was seventy-five years ago.

At the same time, it is necessary to avoid "public health nihilism." Even if we lack the formulas necessary to "cure" poverty and social inequalities, we do have at our disposal the cure for almost all cases of tuberculosis. Those who remain committed to addressing tuberculosis by championing increased access to effective drugs must resist restricting their field of analysis of the tuberculosis problem. We are told to choose, in Haiti and in much of Africa, between treating tuberculosis and treating malnutrition. We are told to choose, in Peru, between treating those with susceptible and resistant strains. We are told to choose, in Harlem, between more funding for tuberculosis and more funding for affordable housing. Calls for more ambitious interventions are trumped by a peculiarly bounded utilitarianism: such interventions, we're told, are not "cost-effective." The inadequacies, the multiple ironies, of such analyses are not lost on the poor. In Peru, for example, it is impossible to ignore that a much-praised tuberculosis program is supported in part by the World Bank, one of the institutions that led to increased suffering-and perhaps to increased tuberculosis risk-for the Peruvian poor.

It is possible, of course, to exaggerate the significance of any one policy change. To cite Dr. Garcia again: "If there had not been fujishock, it would have been something else. In Peru, there's always something beating down the poor." Although Dubos and Dubos mistakenly identify tuberculosis with a time-the nineteenth century-rather than with the inhumane conditions faced by billions on this planet, on another score they are right: "It is only through gross errors in social organization and mismanagement of individual life, that tuberculosis could reach the catastrophic levels that prevailed in Europe and North America during the nineteenth century, and that still prevail in Asia and much of Latin America today." As decision-making power-about social organization and about individual life-comes to be increasingly concentrated in the hands of a very few, we must ask, Who gets to determine the boundaries of analysis? Who is to determine what is "cost-effective" and what is not? As a global economy is "restructured," is there no room for alternative strategies of development? Alternative visions of providing health care to the poor?

Addressing these questions may get at the heart of the meaning of tuberculosis at the close of the twentieth century. If tuberculosis could once be termed "the first penalty that capitalistic society had to pay for the ruthless exploitation of labor", what does it mean now? It is perpetually the lot of the poor to pay this penance?


Paul Farmer, MD, PhD, is a medical anthropologist whose work draws primarily on active clinical practice: he divides his clinical time between the Brigham and Women's Hospital (Division of Infectious Disease) and a small charity hospital in rural Haiti. Through Partners In Health, the public charity he helped to found, his work has focused on the prevention and treatment of diseases disproportionately afflicting the poor. The Program in Infectious Disease and Social Change, which Farmer runs along with his colleagues in the Department of Social Medicine, has pioneered novel, community-based treatment strategies for sexually transmitted infections (including HIV), drug-resistant typhoid, and tuberculosis in resource-poor settings.