Inequality, Infections, and Community-Based Health Care

Yale Journal of Health Policy, Law, and Ethics Volume 5 Issue 1 Yale Journal of Health Policy, Law, and Ethics Article 18 2005 Inequality, Infections, and Community-Based Health Care Evan Lyon Paul Farmer Follow this and additional works at: https://digitalcommons.law.yale.edu/yjhple Part of the Health Law and Policy Commons, and the Legal Ethics and Professional Responsibility Commons Recommended Citation Evan Lyon & Paul Farmer, Inequality, Infections, and Community-Based Health Care, 5 Yale J. Health Pol'y L. & Ethics (2005). Available at: https://digitalcommons.law.yale.edu/yjhple/vol5/iss1/18 This Article is brought to you for free and open access by Yale Law School Legal Scholarship Repository. It has been accepted for inclusion in Yale Journal of Health Policy, Law, and Ethics by an authorized editor of Yale Law School Legal Scholarship Repository. For more information, please contact . Lyon and Farmer: Inequality, Infections, and Community-Based Health Care Inequality, Infections, and Community-Based Health Care Evan Lyon, M.D.* and Paul Farner, M.D., Ph.D. t Advocates for better health care for the world's poor are fond of the mantra that "infections know no boundaries." Part of this logic evokes the reality of our global community, connected by the easy and frequent movement of people across national borders. But this mantra is also meant as a warning, reminding those of us in wealthier nations that we just might not be safe from exposure to the poor, huddled, coughing masses. HIV, tuberculosis, and other infectious diseases on the African continent have been declared a U.S. national security priority.' When the global extent of the multi-drug resistant tuberculosis epidemic was being uncovered-in part by the community-based efforts of our small non-profit health care organization working in the slums of Lima, Peru2-news of exposure to 3 drug-resistant tuberculosis on international flights made headlines. The emergence of SARS and the worldwide fear it evoked mobilized * Resident in Internal Medicine, Brigham and Women's Hospital. Dr. Lyon is a recent graduate of Harvard Medical School and divides his clinical time equally between Boston and central Haiti. t Presley Professor of Medical Anthropology, Harvard Medical School. Dr. Farmer, a physician and anthropologist, is the founding director of Partners In Health. 1. NAT'L INTELLIGENCE COUNCIL, NIE 99-17D, THE GLOBAL INFECTIOUS DISEASE THREAT (2000), http://www.cia.gov/cia/ AND ITS IMPLICATIONS FOR THE UNITED STATES Is Declared Threat to Security, AIDS reports/nie/report/nie99-17d.html; Barton Gellman, Al. WASH. POsT, Apr. 30, 2000, at 2. Carole Mitnick et al., Community-Based Therapy for Multidrug-Resistant Tuberculosis in Lima, Peru, 348 NEw ENG.J. MED. 119, 120 (2003). 3. Thomas A. Kenyon et al., Transmission of Multidrug-Resistant Mycobacterium Tuberculosis During a Long Airplane Flight, 334 NEw ENG. J. MED. 933, 933 (1996) ("The transmission of Mycobacterium tuberculosis that we describe aboard a commercial aircraft involved a highly infectious passenger, a long flight [Honolulu-Chicago-Baltimore-ChicagoHonolulu], and close proximity of contacts to the index patient."); see also M.A. Miller et al., Tuberculosis Risk After Exposure on Airplanes, 77 TUBERCULE & LUNG DISEASE 414, 415 (1996) ("The index case [a Russian refugee] in this study flew from Moscow, Russia to Frankfurt, Germany in March 1993. There he boarded a flight originating in Bombay, India destined for New York City. In New York, he changed aircraft and flew to Cleveland, Ohio."). Published by Yale Law School Legal Scholarship Repository, 2005 1 Yale Journal of Health Policy, Law, and Ethics, Vol. 5 [2005], Iss. 1, Art. 18 YALE JOURNAL OF HEALTH POLICY, LAW, AND ETHICS V:I1 (2005) unprecedented resources in a very short period of time.4 While it may seem that our increasingly connected world is getting smaller, the boundary of inequality that separites the world's rich and poor remains very much intact. In fact, the gap between the haves and the have-nots is widening. And if we admit that there are material differences between the living conditions of the vast majority of the world's poor in the global South and those living in the developed world, then inequalitiesnot just economic, but also gender, racial, ethnic, and religious-emerge as important determinants of health. The relationship between poverty, other forms of inequality, and poor health remains whether making comparisons between countries or within a nation. For example, our poorest patients in Boston, Massachusetts do not suffer from malaria or typhoid (as our patients in rural Haiti do), but they are at increased risk for diabetes, cardiovascular disease, obesity, and disability from mental illness or addiction. Certainly, infectious diseases are not equitably distributed. Sub-Saharan Africa holds ten percent of the world's population, but is home to two-thirds of people living with HIV.6 In the United States, more than half of new HIV infections are in the black community, which represents only thirteen percent of the population. 4. Writing about SARS, Jerome Singh claims that there are fast and well-funded responses to epidemics threatening affluent countries. Jerome Singh, SARS, A Challengefrom the South, 423 NATURE 585, 585 (2003); see also Paul Farmer, SARS and Inequality, 276 THE NATION 6, 24 (2003). 5. The World Bank estimates that over one billion people live on less than one U.S. dollar per day; 2.7 billion-representing over fifty percent of the world's population at the last calculation in 2001-live on less than two U.S. dollars per day. For more information, see The World Bank Group, Global Poverty Monitoring, http://www.worldbank.org/ research/povmonitor/ (last visited Nov. 5, 2004). A World Bank summary paper found that 'there was a net decrease in overall incidence of consumption poverty over 1987-98. But it was not enough to reduce the total number of poor by various definitions." SHAOHUA CHEN & MARTIN RAVALLION, DEV. RESEARCH GROUP, WORLD BANK, How DID THE WORLD'S POOREST FARE IN THE 1990S? 1 (2000), http://www.worldbank.org/research/povmonitor/pdfs/ methodology.pdf. The authors "point to two main proximate causes of the disappointing rate of poverty reduction: too little economic growth in the poorest countries and persistent inequalities that inhibited the poor from participating in the growth that did occur." Id. For in-depth analysis of the relationship between poverty, international financial structures, inequality, and health, see JIM Y. KIM ET AL., DYING FOR GROWTH: GLOBAL INEQUALITY AND THE HEALTH OF THE POOR (2000); and MEREDITH FORT ET AL., SICKNESS AND WEALTH: THE CORPORATE ASSAULT ON GLOBAL HEALTH (2004). 6. Joint United Nations Programme on HIV/AIDS [UNAIDS], Sub-Saharan Africa, at http://www.unaids.org/EN/Geographical+Area/By+Region/sub-saharan+africa.asp (last visited Nov. 5, 2004). https://digitalcommons.law.yale.edu/yjhple/vol5 (...truncated)