This glossary is the work of individual University of Washington faculty and graduate students.
It is designed to help student readers understand key terms in Tracy Kidder’s Mountains Beyond
Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World (New York:
Random House 2003), but it also introduces and explains terminology that Paul Farmer uses
himself in his own writing. Where terms are shown in bold in an entry they also have their own
entries too. At the end of each entry the author’s name and email are noted in brackets. The
entries have all been edited both for ensuring their relevancy to understanding Farmer’s work
and for the sake of stylistic coherence. They remain nevertheless the principal work of their
authors.
OF TERMS
A-H
I-O
AIDS/HIV
Accumulation by Dispossession
AMC (Areas of Moral Clarity)
Appropriate Technology
Catchment Area
Cultural Relativism
Deprivation
DQ, Drama Queen
Fiscal Austerity
Global North
Global South
Globalization
Health Geography
Identity Politics
Inequality
IMF
Infectious Disease
Kwashiorkor
Liberation Theology
Malaria
Medical Anthropology
Medical Geography
Morbidity
Mortality
MDR-TB
Neocolonialism
Neoliberalism
O for the P
P-Z
Political Ecology of Disease
Political Economy
Privatization
Prophylaxis
Public Health
Social Determinants of Health
Social Medicine
Structural Adjustment Programs
Structural Violence
TB
TBMI
Typhoid
Washington Consensus
GLOSSARY
AIDS/HIV AIDS is an acronym for Acquired Immune Deficiency Syndrome and HIV is an
acronym for Human Immunodeficiency Virus. AIDS is an autoimmune disease that became a
global concern in the early 1980’s after it began to manifest itself in groups of gay men in
Western countries. AIDS is caused by HIV which is a virus that
progressively overcomes an individual’s immune system such that
the body is eventually unable to fight off secondary diseases or
infections. While HIV transmission occurs primarily through
unprotected sexual intercourse, the virus is also passed from mother
to child as well as through intravenous drug use or contaminated
blood supplies. While the vast majority of HIV transmission occurs
through heterosexual intercourse, “outside of Africa, UNAIDS
estimates that one of three HIV infections is now due to injecting
drug use” (IHRD, 2006). Global statistics about HIV/AIDS are astounding, frightening, and
demonstrate why this disease is a top global health priority in the twenty-first century. Since HIV
emerged in the human population, more than 70 million people have been infected “and at least 5
million people are being infected each year—some 15,000 per day” (Hunter, 2005). There is no
cure for HIV or AIDS, only (scarcely available and very costly) antiretroviral drugs to retard its
progress in weakening the body’s immune system.
It is now believed that AIDS has killed more people than the Spanish Flu pandemic of 19181919, the former deadliest disease in recorded human history (Drexler, 2003). Forecasts suggest
that there will be several hundred million cases of AIDS/HIV globally by the time the disease
prevalence crests in places where it is just now drawing attention and concern of global health
officials, particularly the Asian continent (Hunter, 2005). Most are familiar with compelling
statistics from Africa about the disease’s scourge on that continent, but we must remember that
Africa is not a particularly populous continent when compared to Southeast Asia and the Indian
subcontinent. If the disease follows similar trends as it has in Africa, the already frightening
numbers of those infected will be absolutely cataclysmic within the next half century. Beyond
statistics, pathology, and geography of the disease, AIDS—a totally preventable disease—
unequally impacts the world’s poor, vulnerable, and marginalized. Maps of poverty-stricken
regions predict places with high numbers of AIDS/HIV cases with great precision. We now
know that HIV strikes populations indiscriminately and does not prefer any gender, ethnicity, or
sexual orientation, but does “disproportionately [strike] the poor and vulnerable” (Farmer, 1992:
258). Because the disease proliferated in the West first among gay men and because to this day
the disease impacts vulnerable populations of the world’s poor the most, the situation of those
enduring its ravages illuminates how the experience of disease reflects gender imbalances, power
imbalances, racial and ethnic disparities, poverty, lingering impacts of Colonialism and
Imperialism, environments of inequality, etc, and why a social medicine approach to treating
the disease is so invaluable. Stigma and AIDS have always gone hand in hand. As Farmer wrote
in his book, AIDS and Accusation, “as long as we have known about AIDS, blame and
accusation have been prominent among the social responses to the new syndrome. These
responses have been prominent enough to be labeled by many the ‘third epidemic’, eclipsing, at
times, the epidemics of AIDS and HIV” (Farmer, 1992: 258). Farmer wrote AIDS and
Accusation after completing fieldwork in Haiti during the mid- to late-1980’s, a time when
Haitians were erroneously labeled as the source of the disease in both scholarly and popular
media. This accusation is now known to be false and Farmer meticulously traces how affluent
American tourists likely brought the virus to Haiti. Like most diseases, people living with
AIDS/HIV have been discriminated against and reviled for behavior causing them to contract the
disease without a critical engagement of concepts such as choice, agency, free-will, and morality.
Unfortunately, biomedicine is often complicit in furthering this stereotyping by creating ‘risk
categories’ and labeling particular populations as more susceptible than others. In the early
stages of the AIDS/HIV epidemic, without any compelling evidence (but with a healthy dose of
racism and snap judgments), Haitians were banned from entry to the United States if they were
HIV+ and all Haitians were banned from blood donation, regardless of HIV status. To this day,
gay men in the United States are forbidden by law from donating blood for any cause, a
Draconian measure leftover from the early days of the epidemic when gay men were blamed for
the disease and all assumed to be carriers. The lessons above teach of the importance of level
headedness when addressing epidemics, making a strong commitment to health for all, and
challenging the human tendency to blame the victims of diseases.
References
Drexler, Madeline. (2003). Secret Agents: The Menace of Emerging Infections. New York:
Penguin.
Farmer, P. (2005). Pathologies of Power: Health, Human Rights, and the New War on the Poor.
Berkeley: University of California Press.
Farmer, P. (1992). AIDS and Accusation: Haiti and the Geography of Blame. Berkeley:
University of California Press.
Hunter, S. (2005). AIDS in Asia: A Continent in Peril. New York: Palgrave Macmillan.
IHRD. (2006). Harm Reduction Developments: Countries with Injection-Driven HIV
Epidemic.New York: International Harm Reduction Program of the Open Society Institute.
Todd Faubion (tfaubion@u.washington.edu)
ACCUMULATION BY DISPOSSESSION The enrichment of the business class through the
deprivation of the poor. The story of the building of the Peligré dam in Mountains Beyond
Mountains is a clear example, with downstream benefits of power flowing to agribusiness and
sweatshop owners, and upstream immiseration for all the farmers whose land was flooded by
Lac Peligré. The actual term ‘accumulation by dispossession’ was coined by the geographer
David Harvey to describe the forced removal of free or public means of subsistence such that
people become more dependent on private businesses for their everyday needs. According to
Harvey this is a process that has always been part of capitalist globalization, but which has also
increased in intensity and scope since the 1970s as a result of neoliberalism (Harvey, 2005).
Neoliberal policies such as privatization and fiscal austerity (government cutbacks) have
thereby led to people being systematically dispossessed of resources and support systems that
were once publicly available and widely shared without the mediation of the capitalist market.
The privatization of medicine is a particularly clear example of this process, and many of the
problems that Paul Farmer sees in ‘market-based medicine’ are related. They include: the
creation of a fee-based health sector with the attendant dangers of the poor receiving little or only
intermittent care; the more general emphasis on individual patients being made wholly
responsible for their own care; and, of course, the profiteering of the pharmaceutical industry and
its transformation of scientific innovations into so-called intellectual property (see Farmer, 2005:
Chapter 6 especially). It is because of the latter forms of accumulation by dispossession, that the
challenges of addressing AIDS/HIV on a global scale are so vast. Antiretroviral drugs produced
by major pharmaceutical companies are protected by intellectual property and patent laws that
keep the drugs out of reach for the vast majority of those whose lives would be significantly
prolonged were they given access. Paul Farmer has managed, in Haiti at least, to get the cost
down to something like $200 per patient per year versus the $10K per person per year cost in the
US, but that took significant effort and a lot of string-pulling (not to mention public shaming of
the industry).
Harvey himself also lists a whole set of non-medical examples of accumulation by dispossession.
Corporate raiding of pension funds, and the speculative raiding of currencies by hedge funds, are
two extreme examples he uses, but his list is much longer than this. “Wholly new mechanisms of
accumulation by dispossession have also opened up,” he says. “The emphasis upon intellectual
property rights in the World Trade Organization negotiations (the so-called TRIPS agreement)
points to ways in which the patenting and licensing of genetic material, seed plasma, and all
manner of other products can now be used against whole populations….The escalating depletion
of the global environmental commons (land, air, water) and proliferating habitat degradations
that preclude anything but capital-intensive modes of agricultural production have likewise
resulted from the wholesale commodification of nature in all its forms” (Harvey, 2003: 148).
Following this broad definition of the process we can see how some of the Haitian developments
highlighted by Farmer as a cause of sickness amongst his patients can also be understood as
examples of accumulation by dispossession. Most notably the creation of the water refugees by
the construction of the Peligré Dam is of a piece with the process, producing wealth for a few
downstream industrialists and at the same time as it dispossessed many poor farmers living
upstream of their basic means of subsistence. Understanding how such developments transform
nature as they turn it into a commodity is one of the central concerns of geographers and other
theorists of political ecology.
Reading
Farmer, Paul. (2005). Pathologies of Power: Health, Human Rights, and the New War on the
Poor. Berkeley: University of California Press.
Harvey, D. 2003. The New Imperialism. Oxford: The University of Oxford Press.
Harvey, D. 2005. A Short History of Neoliberalism. Oxford: The University of Oxford Press.
Matthew Sparke (sparke@u.washington.edu)
AMC is used by the Partners in Health team for “areas of moral clarity.” The acronym emerges
in Mountains Beyond Mountains and refers to those situations “rare in the world, where what
ought to be done seem[s] perfectly clear. But the doing [is] always complicated, always difficult”
(p.103). Complications and difficulties serve as excuses for not responding to the situation itself.
Such challenges may include the presumption of cost-effectiveness of prevention over treatment,
the emphasis on appropriate technology given constraints of resource-limited settings, or
employing an approach that addresses the contingencies and factors that led to the problem,
rather than addressing the situation itself. However, when struck with the image of an individual,
wasting away in a shack in rural Haiti, the obvious response is to do something directly,
urgently, in order to relieve suffering. Since treatment and palliative care exist, the obvious
response is to deliver. Farmer and his team refuse to be convinced of the economic rationality
behind rationing resources. They criticise TBMIs and more broadly the neoliberalism which
drives the economic ‘cost efficacy’ approach to primary health care. Instead, Farmer and his PIH
colleagues slice through the complications and difficulties, sometimes covertly and sometimes
very publicly, to achieve much more caring and humane results. One of the benefits of
Mountains Beyond Mountains is that Kidder provides his readers with an inside view of how
Farmer operates. Readers are privy to Farmer’s self-reflexive and acute awareness of his own
role in participating in and/or resisting external constructions of right and wrong. The times
when he stages health and disease in simplified terms he uses that staging to impart a heightened
sense of urgency and moral imperative to address health inequities. When this occurs in
Mountains Beyond Mountains, Kidder shows us urgent situations in Haiti, and by allowing Haiti
to be presented this way, the book gives readers themselves the opportunity to identify some of
Haiti’s AMCs.
Sarah Paige (spaige2@u.washington.edu)
APPROPRIATE TECHNOLOGY This term is mentioned in Mountains Beyond Mountains in
a conversation Farmer recalls that he had with priest Père Lafontant (Kidder, 2003: 89-90), while
Farmer was completing a health census of Cange. When Farmer questions Lafontant as to
whether the construction of latrines was a use of “appropriate technology,” Lafontant is angered.
As explained by Kidder, “appropriate technology” is often used within the international public
health sphere to employ and provide health care with the most basic resources available. On the
one hand it is senseless to purchase complex medical diagnostic equipment and try to use it in a
region where electricity is scarce. However, one should question why a region lacks adequate
electricity in the first place or more generally, why some individuals have access to these
technologies and services while others lack even the most rudimentary forms of health care.
When Farmer absconds with a Harvard Medical School microscope to use in Cange, he feels that
this is a form of “redistributive justice,” or an AMC, where he is doing what is morally right if
not technically right and proper!
Appropriate technology does not only apply to medical equipment; it is also commonly used
when discussing treatment for medical conditions in developing countries. Prevention, rather
than treatment of infectious diseases (such as AIDS/HIV and MDRTB) is often stressed for
developing countries within international health literature because they are viewed as “limited
resource settings.” The dominant opinion being that it is too difficult and not cost-effective to
treat infectious diseases within the context of developing countries – countries that have limited
resources and access to health care. Rather than questioning why resources are limited, this
ideology provides a way out for medical professionals and political leaders to shirk their
responsibility to provide preventative health care and treatment.
Much of Farmer’s work counters this argument. Throughout his book, Pathologies of Power
(2005), Farmer dismantles these apolitical notions that underlie most of the international health
forum by connecting political and economic decisions which adversely affect human health. The
compelling and successful work carried out by Farmer in conjunction with his colleagues is
exemplary and provides proof that infectious disease can be combated in regions plagued with
poverty and despair.
Particularly in the case of AIDS/HIV, studies have focused primarily on “risk groups” and sexual
behavior vis-à-vis underlying issues such as gender inequality and poverty, which have helped
fuel the global pandemic (Craddock 2000). Similar to the emphasis upon using appropriate
technology, this opinion regarding treatment of infectious diseases in developing countries can
be viewed as a form of cultural relativism. Cultural aspects of a disease (e.g. commercial sex
workers in sub-Saharan Africa) are scrutinized as the source and spread of an infection as
opposed to the more likely culprits such as increasing urbanization, structural adjustment
programs, and poverty (Kalipeni et al. 2004; Lurie et al. 2004). Viewed through the lens of
cultural relativism then, limiting treatment of infectious diseases in developing countries
becomes seemingly justified. When applied in this manner, appropriate technology undercuts the
notion of health care for all as well as attaching differential values to human life. As translated in
terms of economic inequalities, as Lafontant did for Farmer: “It [appropriate technology] means
good things for rich people and shit for the poor” (Kidder, 2003:90).
References
Craddock, S. (2000). “Gender, Identity and Risk: Rethinking the Geography of AIDS.”
Transactions of the Institute of British Geographers 25:153-168.
Farmer, P. (2005). Pathologies of Power: Health, Human Rights, and the New War on the Poor.
London: University of California Press, Ltd.
Kalipeni, E., Craddock, S., & Ghosh, J. (2004). “Mapping the AIDS Pandemic in Eastern and
Southern Africa” in AIDS in Africa: Beyond Epidemiology. Malden: Blackwell Publishing.
Kidder, T. (2003). Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who
Would Cure the World, New York: Random House.
Lurie, P., Hintzen, P.C., & Lowe, R.A. (2004). “Socioeconomic Obstacles to HIV Prevention
and Treatment in Developing Countries: The Roles of the International Monetary Fund and the
World Bank.” AIDS in Africa: Beyond Epidemiology Malden: Blackwell Publishing.
Michelle Bilodeau (micheb3@u.washington.edu)
CATCHMENT AREA: the area and population from which some service or entity draws its
clients. Catchment areas vary dramatically across scales; while an ill individual might not be
willing to travel terribly far to visit a primary care physician, if able he or she will probably
travel great distances to access a life-saving treatment for an illness. In most of the Global North,
catchment areas assume the capacity to travel without great hardship to the necessary health
service and that basic services will be easily available,
but such principles do not hold well in the Global
South in an impoverished country like Haiti. Zanmi
Lasante’s catchment area is absolutely enormous, being
the only healthcare provider for the entire central
plateau area (see image). Zanmi Lasante’s community
health workers serve about one hundred thousand
people in their direct, localized catchment area but one
million peasant farmers rely on Zanmi Lasante for
heath care services (Kidder, 2004). Kidder richly details
his physical exhaustion when traveling with Dr. Farmer
to administer care to patients in remote parts of
mountainous central Haiti; these same patients, when
needing to access medical care through Zanmi Lasante,
must make the journey while ill and often without financial resources to pay for transportation
services. Farmer has a vision of community-supported and sustained healthcare clinics that are
easily accessible and equipped to meet basic health needs (and in a more visionary sense, to
address complex or traumatic health crises), yet Zanmi Lasante is the only such entity for this
vast region of Central Haiti and beyond. For a discussion of catchment areas and for a
continuation of many other themes found in Paul Farmer’s texts, consider enrolling in
Geography 280, 380, or 480—all medical/health geography courses of profound value to those
concerned with global health matters.
Reference
Kidder, T. (2003). Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who
Would Cure the World, New York: Random House.
Suggested Courses:
GEOG 280 Introduction to the Geography of Health and Healthcare (5)
Concepts of health from a geographical viewpoint, including human-environment relations,
development, geographical patterns of disease, and health systems in developed and developing
countries.
GEOG 380 Geographical Patterns of Health and Disease (4)
Geography of infectious and chronic diseases at local, national, and international scales;
environmental, cultural, and social explanations of those variations; comparative aspects of
health systems.
GEOG 480 Environmental Geography, Climate, and Health (5)
Demonstrates and investigates how human-environment relations are expressed in the context of
health and disease. Local and global examples emphasize the ways medical geography is situated
at the intersection of the social, physical, and biological sciences. Examines interactions between
individual health, public health, and social, biological, and physical phenomena.
Todd Faubion (tfaubion@u.washington.edu)
CULTURAL RELATIVISM is an anthropological model of interpretation that seeks to analyse
beliefs and activities as a function of a specific culture. It originally served anthropologists
methodologically as a way to articulate cultural differences and as a framework for comparison
and reflection upon different cultural norms in different places. However, in many cases the
principle of cultural relativism has been inappropriately transformed into one of moral
relativism, wherein universal moral principles or ethical concerns about equal rights and justice
for all are pre-emptively dismissed. Such dismissals, while articulated in the name of giving
every culture its due, can ironically undermine efforts to understand, relate or even communicate
across cultures by deeming such efforts either a new form of Western Imperialism or impossible
because of the power of one’s own cultural filter. Thus a common problem deriving from
cultural relativism is its distancing and ‘othering’ which either obscure or actively curtail
interpersonal connections. Such disconnections allow one to view a situation from a position of
complete absolution of responsibility or participation. In Farmer’s Infections and Inequalities
(1999) there is a still deeper criticism of cultural relativism. He argues thus that cultural
relativists end up justifying inequalities and unequal treatment for different communities in terms
of local cultural norms. As a result, he cautions, cultural difference “is conflated with structural
violence” (Farmer, 1999: 257). In other words, the explanation for poor health or certain courses
of disease equates culture as an independent variable or the only causal force at work instead of
examining the broader social, political and economic forces that shape outcomes on the ground.
Farmer is not calling for the dissolution of culture; he simply rejects the notion that simplified
cultural categories can be used to explain health status and subsequently be used as an excuse for
inaction.
Reference
Farmer, P. (1999). Infections and Inequalities: The Modern Plagues. Berkeley. University of
California Press.
Sarah Paige (spaige2@u.washington.edu)
DEPRIVATION: broadly referencing the loss of something fundamental to living a healthy and
productive life (occupation, political representation, land or natural resources, transportation,
food, water, etc.), deprivation also refers to extreme poverty. Deprivation can be seen as the loss
of ability to control one’s life direction (agency) and very right to livelihood. When considering
deprivation, the concept of ‘entitlement’ carries important meaning as well. Considering the
basic rights human beings are entitled to and the minimum standard citizens of the world should
be responsible for providing to the less well-off is a valuable way to channel concerns about
deprivation into action. In the context of Mountains Beyond Mountains deprivation is a term
intimately connected to inequality and human rights; Farmer makes the argument that not only
are the majority of Haitians poor, but on a daily basis their core human rights are violated by a
lack of economic and social opportunities, lack of access to healthcare, ongoing processes of
accumulation by dispossession, and multiple violations of Haitian sovereignty throughout its
turbulent history. While the most acute deprivation lies
in lack of access to right-to-life commodities like food,
safe drinking water, and shelter, we must have a
sufficiently broad definition of deprivation such that
people who endure centuries of structural violence are
also conceived of as being deprived of their right to
productive, meaningful lives. Specifically relating the
concept of deprivation to health and illness, if we accept
Farmer’s idea that “the degree to which patients are able
to comply with treatment regimens is significantly
limited by forces that are simply beyond their control”
(1999: 241), human beings are chronically denied their
very right to health and livelihood. In Haiti, Farmer demonstrates how deprivation creates severe
blockages to health. For instance, the treatment regimens for tuberculosis and AIDS/HIV are so
complex that without a proper support system (housing, nutritious diet, monitoring by a clinician,
etc.) and infrastructural capacity, those needing treatment will not be able to access or adhere to
the regimen. To measure deprivation, we must have a standard from which to work, and that
standard is relatively defined. For a list of examples citing how deprivation can be defined and
its myriad meanings, type the term ‘deprivation’ into a United Nations (http://www.un.org)
search engine and both its importance and multiple meanings will become clear.
Reference
Farmer, P. (1999). Infections and Inequalities: The Modern Plagues. Berkeley: University of
California Press.
Todd Faubion (tfaubion@u.washington.edu)
DQ or DRAMA QUEEN One of the numerous code word acronyms used throughout Kidder’s
book, drama queen is often used to characterize the deliberate but also self-critical dramatization
of the suffering faced by the poor in developing nations such as Haiti . For Farmer and the other
Partners in Health activists the term seems thus to signal a double set of challenges of bearing
witness to poverty and ill-health. On the one hand these challenges involve deliberately
documenting suffering so that it gets noticed by people in elite organizations and rich countries
who make decisions that affect international health. The search for the DQ example is in this
sense motivated by an attempt to give voice to the recriminations and vocabulary of suffering
spoken by the poor and sick themselves. “Structural violence,” Farmer explains in Pathologies
of Power, “generates bitter recrimination, whether it is heard or not. And given that residents of
the barrio and the cities and neighborhoods like it are those that endure most of the world’s
misery, they are precisely those most likely to have a vocabulary to explain a degree of pain, its
position or nature” (Farmer, 2005: 25). On the other hand, though, the fact that Farmer and the
Partners in Health organizers use the term DQ to describe their efforts to relay the voices of the
poor indicates in turn that they are aware of the dangers of misrepresenting and/or further
exploiting the poor in doing so. As Farmer cautions in the chapter on ‘Bearing Witness’ in
Pathologies of Power, “writing of the plight of the oppressed is not a particularly effective way
of assisting them.” Aware that everything said about the poor may be used against them, he notes
thus that: “I hope to have avoided lurid recountings that serve little purpose than to show, as
anthropologists love to do, that I was there” (2005: 26). It is in this same self-critical vein that the
notion of being a Drama Queen functions in the Partners in Health lexicon as a caution about
ever being sanctimoniously self-serving in bearing witness to the suffering of others. Always
aware of the dangers of overdramatization, Farmer nevertheless persists in relaying and
recounting numerous stories of the personal suffering individual Haitians have endured both
within and outside their tumultuous nation. His own writings are therefore filled with
extraordinarily sensistive DQ moments. For example, one such narrative concerns a woman by
the name of Yolande Jean tells of her unimaginable experience while being held prisoner at the
Guantánamo Bay U.S. military base after trying to escape by sea from Haiti (57-66). There,
along with countless other Haitians that had been captured en route by U.S. soldiers, Yolande
was continuously beaten and deprived of even the most basic supplies such as clean water and
shelter. After a mandatory HIV screening, where Yolande’s results came back positive, her
human rights were further grossly violated by being forced to take contraceptives to prevent
transmission of HIV to an unborn child. Farmer reiterates Yolande Jean’s story not to provide
“anecdotal” stories, but to convey how individuals such as Yolande Jean and millions of Haitians
are victims whose treatment is unwarranted and inhumane. Farmer (2005, 31) states: Millions of
people living in similar circumstances can expect to meet similar fates. What these victims, past
and present, share are not personal or psychological attributes. They do not share culture or
language or a certain race. What they share, rather, is the experience of occupying the bottom
rung of the social ladder in inegalitarian societies. Through these real-life experiences, Farmer
communicates the personal suffering of millions of people throughout the world brought upon by
a complex array of political and economic actors. Within Mountains Beyond Mountains, we see
how Farmer’s “narration of Haiti” comes to the forefront of national as well as international
forums. At an AIDS conference held in Massachusetts, Farmer gives a speech in which he stated,
“Cambridge cares about AIDS, but not nearly enough” (Kidder, 2003, 30). During another
conference, Farmer iterates that social inequality and poverty, rather than the behavior of “risk
groups” are probable explanations for rising HIV prevalence (pp.198-99). Within this speech,
Farmer demonstrates how most HIV/AIDS research published does not link issues of gender,
poverty and inequality. While Farmer obviously understands the dangers of overdramatizing
individual stories at the expense of documenting broader patterns of inequality, he equally
clearly feels that dramatic accounts of personal suffering are one of his best means to convey his
message (and the message of the poor themselves) to the global health community.
References
Farmer, P. (2005). Pathologies of Power: Health, Human Rights, and the New War on the Poor.
London: University of California Press, Ltd.
Kidder, T. (2003). Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who
Would Save the World. New York: Random House.
Michelle Bilodeau (micheb3@u.washington.edu)
Matthew Sparke (sparke@u.washington.edu)
FISCAL AUSTERITY A term used to describe governmental policies that are deliberately
designed to cut budgets and reduce government spending. These neoliberal policies generally
lead to cuts in public services, including everything from education and health-care to the
provision of clean water. This is why Kidder uses the term to underline the remarkable
achievement of Peru’s anti-TB program. “In an era of fiscal austerity in Peru,” he notes, “they
had managed to get the government to put up the money for the DOTS” (Kidder, 2000: 145).
Such comments in Mountains Beyond Mountains remind us that, while fiscal austerity sounds
bland and insignificant as a term, its implementation as policy has huge life and death
consequences, consequences which unfortunately tend to be on the side of death unless policymakers are caring and courageous enough to stand up for public health.
Fiscal austerity is at odds with public health spending more generally because it goes against the
mid-twentieth century idea that governments need to step in during downturns in the business
cycle in order to restart economies and keep social life from collapsing in crisis. Neoliberal elites
in institutions like the International Monetary Fund (IMF) disagree with such deficit spending.
They argue that the supposedly short term pain caused by fiscal austerity allows for long term
gain because it will (again supposedly) prevent governments from overborrowing, and from
thereby creating high inflation and the associated risks for business and owners of large amounts
of money (inflation effectively representing a fall in the value of money). Against this, it seems
that even when governments such as Argentina follow the neoliberal rule book and reduce
spending by imposing fiscal austerity they still can fall into inflationary cycles of fast rising
prices and all the attendant economic instabilities. Meanwhile, even if they do not suffer the total
financial meltdown that Argentina went through in 2002-2003, fiscal austerity still takes money
away from the capacity of governments to make the kinds of investments in education and
health-care that ensure the long-run survival of ordinary citizens. Such disinvestment leads not
surprisingly to widespread social upheaval. In the 1980s and 1990s many other parts of the world
that had fiscal austerity forced on them by the IMF and World Bank as one of the main
conditionalities of new loans experienced ‘austerity protests.’ These often started with riots over
foods prices, but usually also extended into broader campaigns against wage cuts, the
privatization of public services and the general decline of social infrastructure (see Walton and
Seddon, 1994). While none of this has forced the IMF to change its policies, it has challenged the
Washington Consensus on the benefits of fiscal discipline and has even forced newspapers like
the New York Times to publish articles second-guessing the merits of ‘austerity.’ “The standard
advice of the [IMF] to clients facing crisis has been to insist on increased austerity,” noted one
journalist who continued to lament as follows. “But that translates into enormous suffering for
millions of people, strengthens the appeal of left wing critics of free market economies and
weakens governments that have made the changes Washington is urging” (Rohter, 2002).
References
Rohter, L. (2002). “Brazilians find political cost for help from IMF,” The New York Times, 25.
September, page 3.
Walton, J. and Seddon D. (1994). Free Markets and Food Riots: The Politics of Global
Adjustment. Oxford: Blackwell.
Matthew Sparke (sparke@u.washington.edu)
GLOBAL NORTH see GLOBAL SOUTH
GLOBAL SOUTH A term used as a kind of catch-all to describe all the countries and peoples
of the world that are poor and less economically developed than the richer countries of the socalled “Global North.” The Global South is thus generally said to include all of Africa, South,
South-West and South-East Asia, Latin America, Central America, and, depending on particular
definitions, the Middle East. The Global South and the North are effectively successors to the
terms ‘Less Developed World’ and ‘Developed World,’ and, before these, ‘Third World’ and
‘First World.’ A common set of problems of overgeneralization tend to haunt all these metageographical categories. Obviously, there are many poor people living in rich countries like the
UK, Australia and the US. The tent cities of Seattle’s homeless population are in this sense every
bit a part of the Global South as the vast slums of urban India. Likewise, the poor Roxbury
neighborhood of Boston where Paul Farmer conducts some of his American clinical work is just
as much part of the Global South as Haiti’s central plateau. A straightforward cartographic
partition between the Global South and North is also frustrated by the fact that there are many
wealthy elites living in cacooned gated communities in poorer parts of the world. Yet, the terms
remain useful and to understand why, it is worth considering their antecedents.
Historically, there were problems with the terminology of ‘Less Developed’ and ‘Developed’
because it tended to support the inaccurate assumption that all aspects of life (including cultural
life and ethical norms) were ‘less developed’ in poor countries. In a different way, the
terminology of the Third World and First World also seemed to many to set up assumptions
about the rich western countries moving first and fastest up some singular road to progress. This
was despite the fact that the ‘Third World’ idea was actually fashioned in the Cold War by
countries in the so-called ‘non-aligned movement’ that did not want to become aligned with
either the Soviets (the Second World) or the US-led capitalist nations (the First World). Since the
Cold War is now over, ‘Third World’ has lost much of that ‘non-aligned’ resonance. So in its
place has come the term, ‘the Global South.’ A clear geographical problem with this new term is
that many of the countries that are most poor and highly indebted are actually in the northern
hemisphere (the Philippines and Bangladesh, for example). At the same time, there are some
wealthy countries (such as New Zealand and Australia) in the southern hemisphere.
Nevertheless, many commentators still use the categories, nuancing them with the same careful
attention one finds in Paul Farmer’s work to the ties between global integration and global
inequality. For example, the geographers Eric Sheppard and Richa Nagar define the global north
as “constituted through a network of political and economic elites spanning privileged localities
across the globe,” and proceed from this globalized definition to argue that the global South is
similarly “to be found everywhere: foraging the forests of South Asia, undertaking the double
burden of house and paid work, toiling in sweatshops within the United States, and living in
urban quasi-ghettoes worldwide” (see Sheppard and Nagar, 2004: 558). The result for these
geographers as well as for many other observers are new, globally distributed, or what Shappard
and Nagar call “fractionated geographies of the global North and South” through which the older
boundaries of nation-states and geopolitics are eclipsed by communities of fate that are
“progressively fractal and closely inter-related.” This does not mean the end of geography at all,
and Sheppard and Nagar insist in this way “that the geographies of resistance and domination
within the South are increasingly being shaped in relation to discursive materialities of terrorism,
invasion, occupation and security, primarily produced and sustained by powerful actors located
in the North” (page 558).
Reference
Eric Sheppard and Richa Nagar. (2004). “From East-West to North-South,” Antipode, 36(4). pp.
557–563.
Matthew Sparke (sparke@u.washington.edu)
GLOBALIZATION “It’s not much of a stretch,” says Paul Farmer in his book Pathologies of
Power, “to argue that anyone who wishes to be considered humane has ample cause to consider
what it means to be sick and poor in the era of globalization and scientific advancement”
(Farmer, 2005: 6). Here, with his characteristic concern for the ill-health of the poor, Farmer
suggests that there is something deeply wrong with the world when all the globe-spanning
interconnections, affluence, and inventiveness commonly associated with globalization have not
led to a global sharing of wealth, the transcendence of global inequalities, and the planetary
dissemination of scientific solutions to common human health problems. To be genuinely
committed to the advancement of global human rights, he argues, we have to remember all those
for whom globalization has only meant more suffering. For the same reason, Farmer suggests,
when we hear happy stories of globalization leading automatically to the spread of scientific
knowledge and shared human development we need to keep asking ‘what about the poor and the
sick?’ Constantly asking this question himself, Farmer reveals a great sensitivity to the ways in
which ‘globalization’ is used in different ways in different contexts. Invoking the ‘era of
globalization’ he indicates a critical savvy about the way the word is often used as an upbeat
buzzword designed to promote a certain kind of free market capitalist development, but at the
same time, by connecting the term to ‘scientific advancement’ Farmer also activates a more
scholarly use of the term as a bracket description for increasing global interconnection. In the
rest of this definition, we will examine how these two uses of globalization have been developed
and how we can follow Farmer in asking critical questions about the political use of the
buzzword without losing sight of how the world really is becoming increasingly interdependent.
Another way of making the point about globalization having both story-telling and descriptive
uses is just to give it two definitions. Thus on the one side we can say it is an academic umbrella
term that is used to describe the ways in which global networks of production, transportation,
finance, media, communication and medical science are integrating the fate of people across the
planet evermore tightly together. And on the other side, we can say it is a political buzzword that
is used by politicians, pundits and activists to hype what they commonly view as an inexorable
juggernaut of global change. While it is easy to posit a double definition, it is not always so
simple to distinguish between the two uses of the term because many commentators tend to run
them together. Typically, for example, proponents of free market reforms jump from noting that
the world is becoming ever more tightly integrated by global networks to claiming that this
necessarily means that we have no choice but to implement the policies of privatization, free
trade, financial deregulation, and fiscal austerity associated with neoliberalism. Here, for
example, is a classic statement of the genre from the New York Times columnist Thomas
Friedman. Globalization, he says, “involves the inexorable integration of markets, nation-states,
and technologies to a degree never witnessed before – in a way that is enabling individuals,
corporations and nation-states to reach around the world farther, faster, deeper and cheaper than
ever before” (Friedman, 1999: 7). Except to note that many less privileged individuals (such as
Farmer’s patients in Haiti) are not enabled to reach around the planet like Friedman, there is little
to disagree with here. However, the columnist then makes the next step towards an
instrumentalization of the term in order to make neoliberal reform seem the only sensible option
for anyone or any government who wants to adapt to this new world order. “The driving idea
behind globalization is free-market capitalism – the more you let market forces rule and the more
you open your economy to free trade and competition, the more efficient and flourishing your
economy will be. Globalization means the spread of free market capitalism to virtually every
country in the world; [it] also has its own set of rules – rules that revolve around opening,
deregulating and privatizing your economy” (Friedman, 1999: 8). While such mistaken leaps
from analysis to automatic, no questions asked, neoliberal policy promotion are very common in
commentary on globalization, it is vital to step back and try as much as possible to separate out
our efforts to make sense of the integrative global networks from our engagement with political
speech that instrumentalizes globalization and makes the term do argumentative work in favor
(or against) particular sorts of policy making.
In terms of the actual networks of global integration, globalization is best understood as the
extension, acceleration and intensification of consequential worldwide interconnections. This is
how one of the most thorough academic examinations available defines the term in a book length
survey of the changing nature of global networks (Held et al, 1999). The four authors argue that
if globalization is conceptualized as “the widening, deepening and speeding up of global
interconnectedness” (page 14), it is also possible to pick it apart as “a process which embodies a
transformation in the spatial organization of social relations and transactions – assessed in terms
of their extensity, intensity, velocity and impact – generating transcontinental or interregional
flows and networks of activity, interaction and the exercise of power” (page 16). The spread of
the networks of health-care practice around the world and the limits of that spread in terms of its
all too limited impact in places such as Haiti can be examined in just such terms. The precision
of this definition is useful also insofar as it provides clear parameters for assessing just how far
global integration dynamics have created globally interdependent communities of fate (and in
their book, the four authors also provide tremendous amounts of empirical data showing the
changing extensity, intensity, velocity and impact of different sorts of space-spanning networks
over time). Additionally, the particular attention to spatial re-organization by Held and his
colleagues is useful insofar as it clearly connects the discussion of globalization with wider
accounts of modern capitalist development. The geographer David Harvey, for example, argues
that because capitalism has constantly worked to reduce the frictions of distance and speed-up
the generation of profit its development from the 16th century to today has systematically led to
‘time-space compression’ (Harvey, 1989).
Focusing more on the resulting long distance ties and capacities of modern societies, the
sociologist Anthony Giddens (1985) has discussed the ability to regulate, manage, trust and
interact with other people at a distance in terms of ‘time-space distanciation.’ Too many
commentators, Giddens (1999) himself amongst them, have tended more recently to describe
globalization as some sort of revolutionary end state in which these features of capitalist
modernization have reached their final globe-spanning fulfilment. However, as another
geographer Peter Dicken (2003) emphasises in one of the most detailed examinations of the remapping of the global economy, the deterritorialization dynamics unleashed by capitalist
development do not represent the end of geography or the end of history, but rather create
tendencies towards integration that are historically very volatile as well as geographically very
uneven in their effects. The revolutionary visions of the end of history and end of geography
nevertheless persist, and the reason is simple: they help support some of the more biased uses of
‘Globalization’ as an instrument for advancing neoliberalism in political speech. If you can say
that Globalization is the end of history and the end of geography – in other words, an inevitable
future becoming real before our eyes – it follows that whatever political programs one associates
with adapting to Globalization are just as unarguably obvious, just common-sense. It is in this
way that Globalization has become an instrumental term put to work in shaping as well as
representing the growth of global interdependency. The University of Puget Sound economist
Michael Veseth who has a wesbite describing these instrumental appeals as ‘globaloney’ has also
written two useful books exploring some of the political work for which the term is used
(Veseth, 1998, and 2005). There are many other valuable academic resources for exploring the
diverse uses of globaloney in practice. A very clear-cut introduction to the neoliberal ideology of
globalism with which writers like Thomas Friedman equate globalization is provided by Manfred
Steger (2002). For a more sophisticated feminist critique of globalization as a monolithic
masternarrative see J-K. Gibson-Graham (1996). And for related discussions of how global-local
relations are imagined in instrumental accounts of globalization see Sparke and Lawson (2003).
References
Dicken, P. (2003). Global Shift: Reshaping the Global Economic Map in the 21 st Century. New
York: Guildford.
Farmer, Paul (2005). Pathologies of Power: Health, Human Rights, and the New War on the
Poor. Berkeley: University of California Press.
Friedman, T.L. (1999). The Lexus and the Olive Tree: Understanding Globalization. New York:
Farrar Straus Giroux, 1999.
J-K. Gibson-Graham. (1996). The End of Capitalism (as we knew it): A Feminist Critique of
Political Economy. Oxford: Blackwell.
Giddens, A. (1985). The Constitution of Society. Cambridge: Polity.
Giddens, A. (1999). Runaway World: How Globalization is Shaping Our Lives. London: Profile
Books.
Harvey, D. (1989). The Condition of Postmodernity. Oxford: Blackwell.
Held, D., McGrew, A., Goldblatt, D. and Perraton, J. (1999). Global Transformations: Politics,
Economics and Culture. Stanford: Stanford University Press.
Sparke, M and Lawson, V. (2003). “Entrepreneurial Political Geographies of the Global-Local
Nexus,” in John Agnew, Katharyne Mitchell and Gerard O Tuathail, eds., A Companion to
Political Geography. Oxford : Blackwell, pages 315 - 334.
Steger, M. (2002). Globalism: The New Market Ideology. Lanham, Md.: Rowman & Littlefield
Publishers.
Veseth, M. (1998). Selling Globalization: The Myth of the Global Economy. Boulder: Lynne
Rienner.
Veseth, M. (2005). Globaloney: unraveling the myths of globalization. Lanham, MD: Rowman
and Littlefield.
Matthew Sparke (sparke@u.washington.edu)
HEALTH GEOGRAPHY see MEDICAL GEOGRAPHY.
IDENTITY POLITICS has two interrelated meanings. The first stems from the ways that social
groups who have been excluded, marginalized and oppressed by ethnic, racial and sexual
identifications have in turn reworked these identities as a basis for resistance and political
organizing. The US civil rights organization known as the NAACP – the National Association
for the Advancement of Colored People – is a classic example of this kind of resistance-based
identity politics, as is NOW – the National Organization of Women. However, today there is also
a second, more critical or at least cautious, usage of the term “identity politics,” a usage that
relates to huge ongoing debates over the limits of identity-based labels in addressing global
injustice. This critical usage highlights the dangers of allowing frozen concepts of racial or
sexual identity in one particular context to become obstacles rather than enablers of social justice
more generally. For instance, the feminist and post-colonial theorist Gayatri Spivak argues that
in a global context feminists need to distinguish between the vice-president of a big corporation
who has learned to say “she” as well “he” and the average macho guerilla fighter in the jungles
of El Salvador (Spivak, 1990). In other words, she and many others are concerned about the
ways in which a narrow “politically-correct” etiquette that responds to identity politics masks
ongoing exploitation and oppression on a global scale. Paul Farmer’s impatience with identity
politics stems largely from similar concerns. His usage is thus of the second, more critical, kind;
however, this still puts his arguments into a certain degree of tension with the older activist
meaning as a name for identity-based political movements.
Identity politics have been a powerful force in American life, and as a rallying point for
resistance have led to many gains for marginalized groups. This means we have to be very
careful to understand where the frustrations of the critics come from. On first glance, it seems
that a social justice advocate such as Farmer would be a proponent of identity politics, since he
repeatedly calls our attention to how global political structures marginalize and/or pathologize
those with certain identities – Haitian and black, for instance. However, Kidder highlights
Farmer’s seeming disdain for identity politics.
[Farmer ridiculed] the misplaced preoccupations of those who believed in “identity politics,” in
the idea that all members of an oppressed minority were equally oppressed, which all too
conveniently obscured the fact that there were real differences in the “shaftedness,” also
sometimes called the “degrees of hose-edness,” that people of the same race or gender suffered.
(Kidder, p. 216)
As this quote illustrates, Farmer’s critique is based in his contention that identity politics can
neglect real material differences among members of a given “identity” group. For instance, the
experience of an educated, middle-class African-American doctor, is very different from that of a
poor Haitian women suffering from AIDS. Both might be identified as “Black” in terms of
identity politics, and both might experience racism in different contexts, but considered in global
economic terms this commonality breaks down. In Mountains Beyond Mountains there is a
moment where this break-down is highlighted by Kidder as being something registered in the
language of Haitians themselves (as well as in the analysis offered by Farmer).
But a blan isn’t necessarily white-skinned; one might say, every blan becomes white by virtue of
being a blan. The African American medical student Farmer had brought here some months
back, for instance. Some people at Zanmi Lasante had wondered if he was Farmer’s brother, and
later some had mistaken another visiting black American student of Farmer’s for the first one,
and when Farmer teased them about this, one of the staff had said – Farmer swore this was true –
“All you blan look alike” (Kidder, p. 36).
This critique of identity politics as obscuring economic differences is not unique to Farmer, and
has clearly been raised by other progressive political thinkers. It resonates with the broader
critique that has been raised against identity politics that it presumes that all members of a
particular social “group” have the same interests, when in fact there may be numerous divisions
within a particular group. And this critique in turn chimes with the more theoretical concern that
a narrow and decontextualized identity politics cements the idea that groupings are natural or
inevitable, rather than socially constructed and hence always open to change (see Brown, 1995
for a feminist version of this argument, and Gilroy, 2000 for an anti-racist version). Nevertheless,
organizing around the basis of an identity can at times be politically strategic and vital. Thus
many progressive scholars and activists today struggle with the balance of advocating for
disenfranchised groups, while recognizing the complexity of identity and the need for coalition
across identities.
For further exploration of identity and identity politics, see the study note on Difference, Identity
and Power by Prof. Anu Taranath. For an analysis of the relationship between structural violence
and identity politics, see the essay on How Research on Globalization Explains Structural
Violence by Prof. Matthew Sparke. Some additional resources you may find useful are:
Alcoff, Linda Martín et al., eds. (2006). Identity Politics Reconsidered. New York: Palgrave
MacMillan.
Brown, Wendy. (1995). States of Injury: Power and Freedom in Late Modernity. Princeton, N.J.:
Princeton University Press.
Gilroy, Paul. (2000). Against Race: Imagining Political Culture Beyond the Color Line.
Cambridge: Harvard University Press.
Kenny, Michael. (2004). The Politics of Identity: Liberal Political Theory and the Dilemmas of
Difference. Malden, MA: Polity Press.
Moya, Paula M. L. (2002). Learning From Experience: Minority Identities, Multicultural
Struggles. Berkeley: University of California Press.
Spivak, Gayatri Chakravorty (1990). The Post-Colonial Critic: Interviews, Strategies, Dialogues.
Edited by Sarah Harasym. New York: Routledge.
Alka Arora (alka@u.washington.edu)
Matthew Sparke (sparke@u.washington.edu)
IMF The International Monetary Fund is an international organization of 183 member
countries. It was set up under US leadership by the Bretton Woods agreement in 1945 at the
close of World War II. At the time it was charged with ensuring the stability of the world
financial system, and, in particular, with dealing with situations in which countries run into short
term financing crises. From the beginning, however, its bias has been towards the protection of
the world's big lenders (wealthy countries, big banks and their shareholders). Over time it has
come to take on more and more of a managerial role in the world economic system. It exercises
this managerial power by setting conditions on what countries should do in order to secure loans
or loan rescheduling arrangements. Since the 1970s the IMF has increasingly expanded and
entrenched neoliberalism in the developing world by calling for structural adjustment
reforms. Poor countries have generally gone along with such reforms – including policies of
deregulation, privatization and fiscal austerity – because it has been the only way to become
eligible for new loans and loan rescheduling. In other words, the IMF has used the mechanism of
debt to enforce compliance with the Washington Consensus (see Peet et al, 2004).
Most of the controversy over the IMF’s role in Haiti turns on the contradictions of structural
adjustment and dissensus over the Washington Consensus. From its own publications the IMF
gives an impression of trying to act in Haiti’s best interests by continually urging reform (see
IMF, 2006). In a 2005 statement about the release of emergency aid to the country, the fund thus
explained that its release of money was justified because: “the Haitian authorities have made
progress toward restoring macroeconomic stability and implementing structural reforms.” As
well as citing Haiti’s implementation of structural adjustment, the same statement also
underlined that this had happened without renewed government borrowing. “They implemented
the 2004/05 budget without net recourse to central bank financing, and tightened monetary
policy in the face of the difficult macroeconomic and security situation as well as delays in donor
disbursements.” (IMF, 2005). Thus is a picture painted of successful structural adjustment.
However, for the critics, including Paul Farmer, this picture paints over an underlying pattern of
structural violence in Haiti. The upbeat bureaucratic language of the 2005 report, for example,
completely obscures the role that the IMF played in concert with the Inter-American
Development Bank (IDB) in undermining President Aristide’s ability to govern after his second
successful democratic victory in the election of 2001. Farmer himself has made this argument,
noting that “in order to meet the renewed demands of the IDB, the cash-strapped Haitian
government was required to pay ever-expanding arrears on its debts, many of them linked to
loans paid out to the Duvalier dictatorship and to the military regimes that ruled Haiti with great
brutality from 1986 to 1990. In July 2003, Haiti sent more than 90 per cent of all its foreign
reserves to Washington to pay off these arrears” (Farmer, 2004). As other critical commentators
have further explained, the terrible financial situation translated in turn to massive social
upheavals that further played into the hands of the Haitian business elites who opposed Aristide.
Michel Chossudovsky of the Canadian Center for Research on Globalization tells the story as
follows:
The country was in the straitjacket of a spiraling external debt. In a bitter irony, the IMF-World
Bank sponsored austerity measures in the social sectors were imposed in a country which has 1
to 2 medical doctors for 10,000 inhabitants and where the large majority of the population is
illiterate. State social services, which were virtually nonexistent during the Duvalier period, have
collapsed. The result of IMF ministrations was a further collapse in purchasing power, which had
also affected middle income groups. Meanwhile, interest rates had skyrocketed. In the Northern
and Eastern parts of the country, the hikes in fuel prices had led to a virtual paralysis of
transportation and public services including water and electricity. While a humanitarian
catastrophe is looming, the collapse of the economy spearheaded by the IMF, had served to boost
the popularity of the Democratic Platform, which had accused Aristide of “economic
mismanagement.” Needless to say, the leaders of the Democratic Platform including Andy Apaid
– who actually owns the sweatshops – are the main protagonists of the low wage economy
(Chossudovsky, 2004).
Even before its involvements in undermining Aristide’s second term in office, the IMF was
involved in earlier instability-increasing interventions in Haiti in the 1990s. One example is the
case of Haitian rice farmers thrown into dire poverty because of Haiti’s implementation of free
trade which in turn allowed highly subsidized rice from the U.S. to flood the Haitian market. A
Washington Post reporter summarized this story as follows:
PONT-SONDE, Haiti – Last month, several dozen impoverished rice-growers and their families
decided they could bear life in Haiti no longer. They pooled their meager savings, bought a
rickety boat and headed northward to the British-administered Turks and Caicos Islands.
Halfway into the 150-mile trip, the vessel capsized, killing all 60 on board. “We are mourning
now, because we lost so many members of our families,” said Emince Bernard, one of the
villagers who remained behind, and who heard about the disaster on the radio. “But the same
thing is going to happen over and over again, because the people here no longer have any hope.”
The plight of Haitian rice farmers provides a human dimension to the debate over the costs and
benefits of globalization as Washington gears up for protests to coincide with the annual
meetings of the International Monetary Fund and World Bank. Organizers of this weekend's
demonstrations have cited the rice growers’ struggle for survival as a prime example of the
failure of free-market policies advocated by the IMF with the strong backing of the United
States. “The IMF forced Haiti to open its market to imported, highly subsidized U.S. rice at the
same time it prohibited Haiti from subsidizing its own farmers,” declares the Web site of Global
Exchange, one of the Third World advocacy groups organizing the Washington protests.
“Haitian farmers have been forced off their land to seek work in sweatshops, and people are
poorer than ever.” Over the past two decades, a period of growing IMF tutelage over the Haitian
economy, exports of American rice to Haiti have grown from virtually zero to more than 200,000
tons a year, making the poverty-stricken country of 7 million people the fourth-largest market for
American rice in the world after Japan, Mexico and Canada (Dobbs, 2000).
This account is a classic case of structural adjustment becoming structural violence. Because it is
structural the violence inflicted by IMF policies is hard to see, but as the stories accumulate the
pattern becomes clear. Haiti is just one example in this regard, and while it is focused on a
neighboring Caribbean country and not Haiti directly, there is a brilliant film entitled Life and
Debt which documents exactly the same sorts of ties between IMF-enforced reform and
structural violence in Jamaica (Black, 2001).
References
Black, S. (2001) Life and debt. New York: New Yorker Films. Odegaard Media Videorecord
NYV 001 .
Chossudovsky, M. (2004) The Destabilization of Haiti, accessed at
http://www.globalresearch.ca/articles/CHO402D.html
Dobbs, M. (2000) Free Market Left Haiti's Rice Growers Behind. Washington Post, Thursday,
April 13: A01.
IMF (2005) “IMF Executive Board Approves US$14.7 Million in Additional Emergency PostConflict Assistance to Haiti,” accessed at
http://www.imf.org/external/np/sec/pr/2005/pr05234.htm
IMF (2006) “ Haiti and the IMF,” accessed at http://www.imf.org/external/country/HTI/.htm
Farmer, Paul (2004) “Who removed Aristide?” London Review of Books, Vol. 26 No. 8 dated 15
April 2004 available online at http://www.lrb.co.uk/v26/n08/farm01_.html
Peet, R. et al, 2003: Unholy trinity: The IMF, World Bank and WTO. London: Zed Books.
Matthew Sparke (sparke@u.washington.edu)
INEQUALITY Lack of equality in terms of treatment, access, opportunities, status,
representation, human rights, etc, indicating disparities along a continuum, often the polar ends
of that continuum. Usually referenced as an economic indicator, “the steep gradient of
inequality” (Kidder quoting Farmer, 2004: 101) draws attention to the vast space between the
few enormously wealthy individuals in the world compared to billions of people who are
desperately poor. Beyond economistic meanings, inequality can reference differences in access
to resources like healthcare or political representation. Extending the definition further than
simply examining numbers and what they highlight about difference, we must pay keen attention
to the social lines that inequality follows: the poor and marginalized are disproportionately
women, live in the Global South, have experienced Colonialism or Imperialism, do not have
access or have been dispossessed of land, etc., versus the world’s billionaires who are almost
entirely men from affluent countries of the Global North. In the context of Mountains Beyond
Mountains inequality is a term with ethical and moral implications and has many scales of
meaning (within Haiti, the Western Hemisphere, the
world); measuring inequality economically, while
valuable, must serve as a point of inquiry—there are
deep historical reasons why relations are unequal
and there are types of inequality (access to
healthcare and political representation, racial
disparities, access to the fruits of the global
economy, etc.) that cannot be measured in strictly
economic terms. Our conception of inequality must
be sufficiently broad such that it serves as an
analytical tool in highlighting why certain places
and populations chronically experience threats to
livelihood and well-being. Analytically, inequality is
a useful concept in casting light on dramatic
differences in the human experience and in encouraging a deep engagement into why difference
exists, why difference varies over time and space, and how unequal relationships are formed and
perpetuated. As Farmer states, “social inequalities—both within affluent societies and across
borders—have risen sharply over the past two or three decades” (2005: 161). Two billion people
live on less than US$2 per day (Sachs, 2005) in the context of upward redistribution of wealth
placing vast amounts of money in the hands of an elite few individuals. This disparity is
intimately related to accumulation by dispossession, a process that further marginalizes the
poor, robs them of their livelihoods, and leaves them increasingly vulnerable to health (and
other) crises. The disparity is summarized well as “entrenched excess and squalor” (Farmer,
2005: 161). In Mountains Beyond Mountains we learn that the majority of Haitians experience
constant malnourishment and deprivation, yet there is an elite group (within Haiti and beyond)
for whom the vast masses of poor people (a cheap labor pool) comfortably subsidize their
privileged existence. Students further interested in inequality should consider enrolling in
Geography 230, Global Inequality, taught by Professor Victoria Lawson. A further brilliant
source speaking to the ravages inequality inflicts on health is the Population Health Forum
(http://depts.washington.edu/eqhlth/), and the Health Olympics ranking. Succinctly stated: “with
greater economic inequality comes worse health—lower life expectancy and higher mortality
rates” (PHP, 2006).
References
Farmer, P. (2005) Pathologies of Power: Health, Human Rights, and the New War on the Poor,
Berkeley: University of California Press.
Kidder, T. (2003) Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who
Would Save the World, New York: Random House.
School of Public Health and Community Medicine. (2003) Population Health Forum, Seattle:
University of Washington. http://depts.washington.edu/eqhlth/
Sachs, J. (2005) The End of Poverty: Economic Possibilities for our Time, New York : The
Penguin Press.
Suggested Courses
SIS 123 Introduction to Globalization (5)
GEOG 230 Urbanization and Development: Geographies of Global Inequality (5)
Todd Faubion (tfaubion@u.washington.edu)
INFECTIOUS DISEASE/ EMERGING INFECTIOUS DISEASE Infectious Disease (ID)
refers to the signs and symptoms associated with the presence of a pathogenic microbe within the
body, causing that person to feel sick. The word ‘disease’ is socially and culturally constructed
as it means an abnormal or uncomfortable state of being (in mind or body). Medical
anthropologists unpack the social and cultural meanings behind the word ‘disease,’ and the
conditions or states of conditions that are called ‘disease.’
Microbes (or pathogens) that cause infectious diseases are typically bacterial, viral, parasitic or
fungal. Infectious disease research focuses on the intersection of three factors: host, agent, and
vector. We often think of a host as a person, an agent as the pathogen, and the vector as either
the intermediate host delivering the agent (like a mosquito carrying the malaria parasite) or as the
mode of transmission (as in contaminated drinking water). Medical geographers who study
infectious disease often focus on the external factors or forces (physical environment, economic
influences, cultural expectations, and sociopolitical pressures) that lead to those three
components interacting.
Emerging infectious diseases are a growing concern as our ability to isolate and control disease
has been weakening for the past 50 years. Emerging infectious disease are infectious diseases
that result from infection by new pathogens, or old pathogens that are considered to be reemerging. The Institutes of Medicine in 2003 identified factors associated with emerging
infections. Those factors reflect concerns that are evident in Medical/Health Geography
studies. “Ultimately, the emergence of a microbial threat derives from the convergence of (1)
genetic and biological factors; (2) physical environmental factors; (3) ecological factors; and (4)
social, political and economic factors” (Smolinski p. 4).
The bulk of infectious disease is experienced by the developing world. An “epidemiological
transition” is associated with development as industrialized nations are plagued by illnesses of
over-consumption, cancers and cardiovascular conditions and have essentially controlled the
presence and impact of infectious disease through the use of antimicrobial medicines and
effective sanitation and hygiene infrastructure. Infectious diseases are largely associated with
poverty and dispossession, as we are all susceptible to one degree or another, to such diseases,
but the infrastructure, prophylaxis and treatment available in industrialized nations essentially
renders infectious diseases controlled.
Highly publicized infectious diseases include AIDS/HIV (viral pathogen), tuberculosis
(bacterial pathogen) and malaria (parasitic pathogen). Such illnesses have galvanized the global
health community and provoked significant prevention and treatment responses across scalefrom international organizations such as World Health Organizations to local, community-based
organizations, like Farmer’s Zanmi Lasante (or Partners in Health). While efforts to prevent and
treat these highly publicized diseases are incredibly laudable, such focused attention, in turn,
often leads to neglect of other infectious diseases.
Paul Farmer is a Harvard trained Infectious Disease medical doctor. This training allowed
Farmer to specialize in identifying and diagnosing infectious diseases through physical,
symptom-based exams as well as via laboratory diagnosis. His experience in Haiti, both during
training and professional practice provides rich exposure to a broad swath of infectious disease
and further solidifies his expertise in infectious disease. Farmer is trained to treat infectious
diseases using available antimicrobial medicines. Many infectious diseases are curable given
access to appropriate antimicrobial medicines. As such, the opportunity for ready treatment is
one of Farmer’s Area of Moral Clarity, or AMCs. The treatment exists, so why not make it
available? Farmer will often refer to his position as a specialist within the infectious disease
community when he utilizes the turn of phrase “Love, ID” to support his professional opinion to
treat.
Reference
Smolinski M, Hamburg M, Lederberg J. eds. (2003) Microbial Threats to Health: Emergence,
Detection, and Response. Washington, DC: The National Academies Press.
Sarah Paige (spaige2@u.washington.edu)
KWASHIORKOR Kwashiorkor is a form of malnutrition caused by dietary protein deficiency.
It is most common in places where the staple diet is cereal, cassava, rice, yams, or plantains; in
places experiencing famine; or in settings where nutritional knowledge is limited. Its
pathophysiology is still not completely understood but is known to involve, in addition to protein
insufficiency, alterations in redox metabolism. Early symptoms of kwashiorkor include fatigue,
irritability, and lethargy. Continued protein deprivation leads to growth failure, loss of muscle
mass, generalized swelling or edema, and diminished immunity. A large, protuberant belly is
common. This has two causes: first, ascites, or fluid accumulation in the abdomen, which is
caused by the diffusion of fluid from the blood circulation into the surrounding interstitial space
to compensate for decreased blood colloidal osmotic pressure, or oncotic pressure, due to a
diminished concentration of large proteins. A second cause for the protuberant abdomen is the
presence of a grossly enlarged liver due to fatty liver. Fat accumulates in the liver due to a lack
of endogenous proteins called apolipoproteins which are responsible for transporting fat from the
liver to elsewhere in the body. Another sign of kwashiorkor that Kidder describes in Mountains
Beyond Mountains is changes in pigmentation such as thinned, reddish hair color in persons
whose hair is normally dark (e.g., “the Children’s Pavilion upstairs, where there always seems to
be a baby with sticklike limbs, the bloated belly, the reddish hair of kwashiorkor” (p. 31); “He
remembered his first view of kwashiorkor. ‘There was a kid with red hair and a bloated belly…’”
(p. 94)). These color changes, called hypochromotrichia, are likely due to deficiency of sulfurcontaining amino acids which are necessary for melanin synthesis. Kwashiorkor can be either
acute or chronic. Chronic kwashiorkor can leave a child with permanent mental and physical
disabilities. The word ‘kwashiorkor’ is derived from the Ga language of coastal Ghana and
means “the one who is displaced,” referring to the development of the condition in the child who
has been weaned from a diet of nutrient-rich breastmilk upon birth of a younger sibling.
References
Fechner A, Böhme CC, Gromer S, Funk M, Schirmer RH, Becker K. 2001. “Antioxidant Status
and Nitric Oxide in the Malnutrition Syndrome Kwashiorkor.” Pediatric Research 49:237-243.
(Available online: http://www.pedresearch.org/cgi/content/full/49/2/237, accessed 7/24/06).
“Kwashiorkor.” Medline Plus Medical Encyclopedia. (Available online:
http://www.nlm.nih.gov/medlineplus/ency/article/001604.htm, accessed 7/24/06).
“Kwashiorkor.” Wikipedia. (http://en.wikipedia.org/wiki/Kwashiorkor, accessed 7/24/06).
Jelliffe DB. 1955. “Infant Nutrition in the Subtropics and Tropics.” WHO (monograph series)
No. 29. Geneva: World Health Organization. (Available online:
http://whqlibdoc.who.int/monograph/WHO_MONO_29_(1ed).pdf, accessed 7/24/06).
Palmer PES, Reeder MM. 2001. “Kwashiorkor.” In The Imaging of Tropical Diseases: With
Epidemiological, Pathological, and Clinical Correlation. 2 vols. New York: Springer-Verlag.
(Available online: http://tmcr.usuhs.mil/tmcr/chapter16/Kwashiorkor.htm, accessed 7/24/06).
Sunil Aggarwal (sunila@u.washington.edu)
LIBERATION THEOLOGY This glossary entry is under construction
MALARIA The term ‘malaria’ comes from Italian and literally means ‘bad air,’ referring to a
prior understanding of its cause. Malaria is in fact a potentially lethal infectious disease caused
not by bad air, but by parasitic protozoa of the genus Plasmodium which are transmitted to
humans when a female Anopheles mosquito carrying the parasites in its saliva bites into skin and
takes its bloodmeal. Four species of Plasmodia are responsible for malaria in humans:
Plasmodium vivax, Plasmodium malariae, Plasmodium ovale, and Plasmodium falciparum. Of
these, P. falciparium is the most virulent and prevalent in Haiti. According to the WHO’s
Guidelines for the Treatment of Malaria, the initial signs and symptoms of this disease include
“headache, lassitude, fatigue, abdominal discomfort and muscle and joint aches, followed by
fever, chills, perspiration, anorexia, vomiting and worsening malaise.” In some cases, persons
infected with malaria experience fever spikes, chills, and rigors at regular, cyclical intervals
corresponding to the lifecycle stages of the parasite population as it thrives, replicates, and bursts
out of red blood cells synchronously. If malaria remains untreated or is treated with ineffective
drugs, severe malaria can develop. This is characterized by one or more of the following
symptoms: coma (cerebral malaria), metabolic acidosis (low blood pH), severe anemia (lack of
iron), hypoglycemia (low blood sugar) and, in adults, acute renal (kidney) failure or acute
pulmonary edema (or fluid build-up in the lungs). Severe malaria is almost always fatal if
untreated. Annually, there are about 500 million new cases of malaria, with approximately 90
percent of these concentrated within sub-Saharan Africa. The WHO estimated that there were
1,124,000 deaths directly attributed to malaria in 2002, with 970,000 in Africa alone. Drugresistant malaria is on the rise, making many first-line drugs such as chloroquine and sulfadoxine
with pyrimethamine ineffective. Several NGOs and international health and development
organizations are working to “roll back” malaria by employing strategies such as increasing
access to effective anti-malarial prophylaxis, treatment, and mosquito nets to halt the spread of
malaria in places hardest hit by this disease. A malaria vaccine is also in development.
References
Guidelines for the Treatment of Malaria. 2006. Geneva: World Health Organization. (Available
online: http://www.who.int/malaria/docs/TreatmentGuidelines2006.pdf, accessed 7/27/06)
Rolling Back Malaria: The World Bank Global Strategy & Booster Program. 2005. Washington,
DC: World Bank. (Available online:
http://siteresources.worldbank.org/INTMALARIA/Resources/3775011114188195065/WBMalaria-GlobalStrategyandBoosterProgram-June2005.pdf, accessed
7/27/06).
Sunil Aggarwal (sunila@u.washington.edu)
MEDICAL ANTHROPOLOGY Not only is Paul Farmer a public health physician and the
driving force behind Partners in Health / Zanmi Lasante, he is also a very active and influential
participant in the scholarly field of medical anthropology. Farmer’s position as an anthropologist
is not to study culture in a removed, distanced fashion, but to understand and relate to it and
identify those core elements of humanity that are common across existences.
Medical anthropology, like Medical Geography, is a subdiscipline that falls under the medical
social sciences. The official website of the Society for Medical Anthropology describes the field
thus:
Medical Anthropology is a subfield of anthropology that draws upon social, cultural, biological,
and linguistic anthropology to better understand those factors which influence health and well
being (broadly defined), the experience and distribution of illness, the prevention and treatment
of sickness, healing processes, the social relations of therapy management, and the cultural
importance and utilization of pluralistic medical systems.…Medical anthropologists examine
how the health of individuals, larger social formations, and the environment are affected by
interrelationships between humans and other species; cultural norms and social institutions;
micro and macro politics; and forces of globalization as each of these affects local worlds.
In other words, medical anthropology examines health and disease beyond the microscope:
beyond simply the bodily manifestations of wellbeing.
Medical anthropologists study such issues as:
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Health ramifications of ecological “adaptation and maladaptation”
Popular health culture and domestic health care practices
Local interpretations of bodily processes
Changing body projects and valued bodily attributes
Perceptions of risk, vulnerability and responsibility for illness and health care
Preventative health and harm reduction practices
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The experience of illness and the social relations of sickness
Ethnomedicine, pluralistic healing modalities, and healing processes
Medical practices in the context of modernity, colonial, and post-colonial social
formations
Disease distribution and health disparity
The political economy of health care provision.
The political ecology of infectious and vector borne diseases, chronic diseases and states
of malnutrition, and violence
The University of Washington offers many resources for students interested in learning more
about medical anthropology. Here are some starting points for exploration:
Medical Anthropology page from the Department of Anthropology website:
https://depts.washington.edu/anthweb/programs/specialty.php
International Health Program website: http://depts.washington.edu/ihprog/
Critical Medical Humanities website: http://courses.washington.edu/cultmed/
Population Health Forum website: http://depts.washington.edu/eqhlth/
Suggested Courses
HUM 201 Diagnosing Injustice: Ethics, Power and Global Health (5) Taylor & Goering.
Surveys the problem of global health disparities, and connections between power and health.
Introduces conceptual tools from medical anthropology and medical ethics for critically
analyzing health and illness in global, social, and ethical perspectives. Topics include poverty
and structural violence, war and terror, biotechnology and pharmaceuticals.
ANTH 374 Narrative, Literature, and Medical Anthropology (5) I& S Taylor Introduces
anthropological perspectives on the workings of narrative in illness, healing, and medicine.
Considers writings in medical anthropology alongside other genres of writing about similar
topics. Readings include memoirs and fiction as well as scholarly articles.
ANTH 375 Comparative Systems of Healing (3) I&S
Introduction to the anthropological study of healing. Examines four healing traditions and
addresses their similarities and differences. Includes anthropological theories of healing and
religion.
ANTH 474 Social Difference and Medical Knowledge (5) I&S Taylor Explores relations
between medical and social categories: how social differences become medicalized; how medical
conditions become associated with stigmatized social groups; and how categories become
sources of identity and bases for political action. Considers classifications (race, gender,
sexuality, disability) and how each has shaped and/or been shaped by medical practice.
ANTH 475 Perspectives in Medical Anthropology (5) I&S
Introduction to medical anthropology. Explores the relationships among culture, society, and
medicine. Examples from Western medicine as well as from other medical systems,
incorporating both interpretive and critical approaches. Offered: jointly with HSERV 475.
ANTH 476 Culture, Medicine, and the Body (5) I&S
Explores the relationship between the body and society, with emphasis on the role of medicine as
a mediator between them. Case study material, primarily from contemporary bio-medicine, as
well as critical, postmodern, and feminist approaches to the body introduced within a general
comparative and anthropological framework.
ANTH 477 Medicine in America: Conflicts and Contradictions (3) I&S
Introduction to the pragmatic and theoretical dilemmas of current biomedical practice with
emphasis on social and cultural context. Case studies in technological intervention, risk
management, and other health-related issues used to explore connections among patients'
experiences, medical practices, and the contemporary social context.
ANTH 478 Introduction to the Anthropology of Institutions (5) I&S Rhodes
Historical, theoretical, and ethnographic perspectives on the study of total institutions, with an
emphasis on prisons and psychiatric facilities. Includes issues of subjection and subjectivity,
institutional social dynamics, and social justice concerns.
ANTH 479 Advanced Topics in Medical Anthropology (3-5, max. 15) I&S Chapman,
Rhodes, Taylor
Explores theoretical and ethnographic advanced topics in medical anthropology. Prerequisite:
permission of instructor.
BIO A 465 Nutritional Anthropology (3) I&S/NW
Concerns interrelationships between biomedical, sociocultural, and ecological factors, and their
influence on the ability of humans to respond to variability in nutritional resources. Topics
covered include diet and human evolution, nutrition-related biobehavioral influences on human
growth, development, and disease resistance. Prerequisite: BIO A 201. Offered: jointly with
NUTR 465.
BIO A 483 Human Genetics, Disease, and Culture (5) NW
Considers relationships among genetic aspects of human disease, cultural behavior, and natural
habitat for a wide variety of conditions. Also considers issues of biological versus environmental
determinism, adaptive aspects of genetic disease, and the role of cultural selection. Prerequisite:
BIO A 201.
(return to )
Resources for Further Study
Joralemon D. (2006). Exploring Medical Anthropology, Second Edition. Boston: Allyn & Bacon.
Janelle Taylor (jstaylor@u.washington.edu)
MEDICAL GEOGRAPHY Medical geography is a subdiscipline of human geography which
can be catalogued alongside other medical social sciences (e.g., medical anthropology).
Medical geography’s unique, multidisciplinary footing creates a three-way bridge among the
social, environmental, and biomedical sciences. One organizing principle of medical geography's
parent discipline is the human-environment relationship, understood in both biophysical and
sociocultural terms. Uncovering human-environment relationships, describing their reflexivity,
patterning, and multiplicity, drives research in human geography and its subdisciplines. That
human-environment relationships are relevant to explaining and understanding patterns of human
health and disease – a core belief of Hippocrates (c. 460 BCE-c. 377 BCE) – is a bedrock
principle of medical geography.
The distinction between medical geography and health geography is the result of debates in the
1990s concerning the dominance of the biomedical establishment and the prevailing value
associated with such approaches. Biomedical understandings of health and disease are typically
lent greater credibility and social prestige and thus are more highly valued compared to
approaches that aim to comprehend health and disease socially and environmentally. This value
system limits the incorporation of non-traditional kinds of knowledge and consequently
comprehends health and disease through a disembodied, distanced perspective. The result is an
epistemic framework for health or disease that lacks traction for those desiring to profoundly
understand subjective experiences of health or disease, psychosocial phenomena, and contextual
effects. Quantitative methods that provide an understanding of health and disease through
mathematics and statistics are often deemed biomedical, whereas qualitative methods that reveal
an understanding of health and disease from more embodied, experiential perspectives are
considered alternative approaches.
Health geography emerged as a response to medical geography that sought to incorporate these
varied, embodied experiences that value non-traditional ways of knowing (Dyck, 1995, Brown
2001). Typically, medical geography is associated with biomedical, quantitative research
approaches, and health geography utilizes qualitative methods. In actuality, the boundary is
fuzzy and the debate has simmered as both medical and health geographers utilize methodologies
appropriate for the research questions at hand, regardless of self-identification. Nevertheless, the
term medical/health geography is selectively adopted and utilized by geographers to indicate a
slight preference of approach or to signal areas of experience.
The upshot of these debates is medical geography’s recognition of the human body as both
materially and socially created, imbued with subjectivity and shaped by interactions with the
environment, thereby incorporating both subjective and objective elements in its account of
human health and disease. This integrated view is critical for a total understanding of human
health and suffering; its persistent application in medicine and public health is certain to help
humankind move toward the goal of achieving, for all, a state of health experienced as “complete
physical, mental and social well-being and not merely the absence of disease or infirmity”– the
visionary goal proffered by the World Health Organization in 1946.
Medical geography's environmentally-driven principles are strengthened by the basic precepts of
ecology by which medical geographers are able to describe dynamic biophysical linkages
between humans, other organisms, and abiotic factors. Increased knowledge and understanding
in the subdiscipline is frequently generated by health-oriented research that focuses on the spatial
interplay between human agents and non-human biological objects. This interplay is
contextualized against the backdrop of an interdependent and interconnected shared
environment, broadly construed to include both biophysical (e.g., terrain, climate, biome) and
social (e.g., public health regulation, political-economic forces, cultural practices) dimensions at
multiple scales, stretching from the local to the global.
Medical and Health Geographers study such issues as:
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Zoonotic disease transmission
Political ecology of health and disease
Geospatial distribution of disease
Healthcare access and delivery
Geographies of illness, impairment, and disability
Therapeutic landscapes
Geographical vulnerability and global peace, security, and sustainability
While Paul Farmer identifies as a medical anthropologist, his work and writings are of central
importance to medical geography. For example, he links health status of the residents of Cange
to the creation of the hydroelectric dam. The dam drove residents off of fertile farmland and
created a group of internal environmental refugees (“the water refugees” p.38) suffering from
infectious disease and malnutrition as a result of displacement. Farmer extends the relationship
of the dam and health outcomes outside of Haiti as he implicates transnational relationships
between industry, government, and foreign policy in the construction of the dam, thereby linking
infectious disease and malnutrition to international political economy. Farmer’s approach to
diagnosis is a political ecology of disease approach, and one many medical geographers employ
to understand, more profoundly, individual and population wellbeing. (return to )
To learn more about medical geography, students are referred to:
Medical Geography Specialty Group: http://www.research.umbc.edu/~earickso/MGSG.html
Ecosystem Approaches to Human Health: http://www.idrc.ca/ecohealth/
Consortium for Conservation Medicine: http://www.conservationmedicine.org/wcm.htm
Suggested Courses (past syllabi here: http://faculty.washington.edu/jmayer/)
GEOG 280 Introduction to the Geography of Health and Health Care (5)
Concepts of health from a geographical viewpoint, including human-environment relations,
development, geographical patterns of disease, and health systems in developed and developing
countries.
GEOG 380 Geographical Patterns of Health and Disease (4)
Geography of infectious and chronic diseases at local, national, and international scales;
environmental, cultural, and social explanations of those variations; comparative aspects of
health systems.
GEOG 480 Environmental Geography, Climate, and Health (5)
Demonstrates and investigates how human-environment relations are expressed in the context of
health and disease. Local and global examples emphasize the ways medical geography is situated
at the intersection of the social, physical, and biological sciences. Examines interactions between
individual health, public health, and social, biological, and physical phenomena.
GEOG 580 Medical Geography
Geography of disease, consideration in health systems planning. Analysis of distributions,
diffusion models, migration studies. Application of distance, optimal location models to health
systems planning; emergency medical services; distribution of health professionals; cultural
variations in health behavior. Prerequisite: familiarity with social science research; health-related
issues.
Resources for Further Study
Brown M, Colton T. (2001) “Dying Epistemologies: An Analysis of Home Death and its
Critique.” Environment and Planning A 33:799-821.
Dyck, I. (1995) “Hidden Geographies: The changing lifeworlds of women with Multiple
Sclerosis”. Soc. Sci. Med. 40:307-20.
Gatrell AC. 2002. Geographies of Health: An Introduction. Oxford: Blackwell Publishers.
Jones K and Moon G. 1992. Health, Disease, and Society: A Critical Medical Geography. New
York: Routledge
Meade M and Earickson R. 2000. Medical Geography. Second Edition. New York: The Guilford
Press.
Sunil Aggarwal (sunila@u.washington.edu)
Sarah Paige (spaige2@u.washington.edu)
Amber Pearson (amberp37@u.washington.edu)
MORBIDITY refers to the incidence (number of new cases in a particular population during a
particular time interval) or prevalence (the total number of cases in a particular population at a
particular point in time) of a disease in a given population; alternatively defined as the quality of
being unhealthy and suffering from an illness. Morbidity refers to sickness, versus mortality,
which refers to death rates. The CIA cites an estimate that in 2003, 280,000 Haitians were living
with HIV (prevalence rate), a likely under-estimation of the magnitude of Haiti’s HIV/AIDS
crisis (World Factbook, 2003). Morbidity rates provide a snapshot impression of the heath status
of a population; when morbidity rates are compared across countries (the scale at which the most
data is available), disparities in health outcomes become starkly apparent and speak volumes
about disparate human experiences.
Reference
Central Intelligence Agency. (2006). The World Factbook: Haiti
https://www.cia.gov/cia/publications/factbook/geos/ha.html.
Todd Faubion (tfaubion@u.washington.edu)
MORTALITY refers to the rate (total number per 1000 people) of death from a specific cause,
ranging from famine to cancer to AIDS. Used to highlight disparities, inequalities, and trends
because, as Farmer states, “rising inequality [contributes] to increasing mortality” (1999: 202).
The CIA cites estimates that the infant mortality rate in Haiti in 2006 was 71.65 (World
Factbook, 2006). The under-five mortality rate is 118.6. This means 118 out of 1000 Haitian
children did not live to their fifth birthday in 2000 (DHS, 2000). Public health officials and
entities are often responsible for gathering morbidity and mortality data; without strong public
health systems, indicators of health are either poor estimates or not available at all (as evidenced
by the scarcely available data on morbidity and mortality in Haiti).
References
Central Intelligence Agency. (2006) The World Factbook: Haiti .
https://www.cia.gov/cia/publications/factbook/geos/ha.html
Demographic of Health Surveys. (2000) Selected indicators for Haiti .
http://www.measuredhs.com/countries/country.cfm?ctry_id=16
Farmer, P. (1999) Infections and Inequalities: The Modern Plagues. Berkeley: University of
California Press.
Todd Faubion (tfaubion@u.washington.edu)
MDR-TB - MULTI-DRUG RESISTANT TUBERCULOSIS
Tuberculosis (TB) is an illness caused by the bacterium Mycobacterium tuberculosis which
usually affects the lungs, but can affect many organs of the body. It is passed fairly easily from
person to person by inhaling bacilli which remain airborne after being expelled by an infected
person who coughs or sneezes. Conditions where people live closely together with poor
ventilation promote the spread of the disease. The WHO estimates that almost one-third of the
world’s population is infected; most of those people do not have symptoms because the primary
infection is contained by the body. The clinical disease of TB may develop if a person’s immune
system is compromised by AIDS/HIV, poor nutrition, alcoholism, or aging, situations made
worse by poverty. In that case, the primary infection is reactivated and the person develops fever,
weight loss, and wasting. According to the WHO, TB accounts for more than one-quarter of all
preventable adult deaths in developing countries. Individuals infected with both TB and HIV
often experience accelerated disease. Anyone can become infected by TB, but poverty increases
the risk of getting TB and decreases the chance of successful therapy.
TB, which was known as “consumption” in the 19th century, affected the rich and the poor and
had no treatment until about 50 years ago. Daily therapy for 6-12 months with at least two
antibiotics (isoniazid and rifampin) will successfully treat TB caused by strains of the bacteria
that are susceptible to those antibiotics. Because of how contagious TB is and how difficult it is
to take multiple medications for months at a time, treatment is usually directly observed by
public health workers. However, the WHO reports that globally, 79% of people with TB do not
have access to directly observed therapy short-course otherwise known as DOTS (WHO, 2006).
Research to develop a TB vaccine and alternative antibiotic therapy is hampered by lack of
profitability as TB becomes more and more a disease of the poor in the U.S. and the rest of the
world.
If treatment is inconsistent or incomplete, or if an ineffective combination of antibiotics for the
particular infection is used, or if drugs become unavailable, strains of TB may develop with
resistance to the usual antibiotics. These infections are very difficult to treat, because more
expensive and complicated second line antibiotics must be used. Worldwide, up to 50 million
people may be infected with multi-drug resistant TB (MDR-TB). A policy of “giving up” on
treating MDR-TB in the developing world because of cost or lack of organization is shortsighted
given the global interconnections which make it impossible to isolate resistant infections, raising
the possibility of worldwide epidemics caused by MDR-TB (see Kim, et al, 2005). Developing
effective treatments for MDR-TB, and being committed to treatment of people with MDR-TB
wherever they live, is crucial for both individual and public health, especially now that even
more challenging drug resistant strains of TB are emerging known as XDR-TB (extremely drug
resistant tuberculosis).
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References:
Kim JY, Shakow A, Mate K, et al. 2005. Limited good and limited vision: multidrug-resistant
tuberculosis and global health policy. Social Science and Medicine, 61: 847-59.
WHO, 2006. Tuberculosis (TB) accessed at http://www.who.int/trade/glossary/story092/en/
Jane Huntington (janehh@u.washington.edu)
NEOCOLONIALISM This is a name for the ways in which long-distance control and
domination over the Global South has continued to be exercised by the world’s wealthy
societies since the formal end of imperialism and its associated colonial practices.
Neocolonialism is distinct from colonialism insofar as it is usually considered to be marketmediated rather than military-mediated. As such, it tends to involve armies of accountants and
bankers rather than soldiers. Organized through the hidden hand of the free market it operates
invisibly (more like radiation than old-fashioned colonial control) having profound affects that
are nonetheless hard to see and track. Che Guevara, the Cuban revolutionary once described
neocolonialism in these ways, as “the most redoubtable form of imperialism – most redoubtable
because of the disguises and deceits it involves” (quoted in Johnson, 2004: 30). Nonetheless, the
continuities with traditional colonialism are there for those who care to notice. In this sense,
perhaps the best description of neocolonialism in the last few years has come from the Indian
writer Arundhati Roy. “Our British colonizers stepped onto our shores a few centuries ago
disguised as traders,” she writes,
We all remember the East India Company. This time around the colonizer doesn’t even need a
token white presence in the colonies. The CEOs and their men don’t need to go to the trouble of
tramping through the tropics, risking malaria, diarrhea, sunstroke and an early death. They don’t
have to maintain an army or a police force, or worry about insurrections and mutinies. They can
have their colonies and an easy conscience. ‘Creating a good investment climate’ is the new
euphemism for third world repression. Besides, the responsibility for implementation rests with
the local administration (Roy, 2001: 17).
References
Chalmers Johnson, 2004: The Sorrows of Empire: Militarism, Secrecy and The End of the
Republic, New York: Metropolitan Books.
Arundhati Roy, 2001: Power Politics, Cambridge, MA: South End Press.
Matthew Sparke (sparke@u.washington.edu)
NEOLIBERALISM Neoliberalism is a name for today’s dominant model of market-based and
business-friendly government. For Paul Farmer and other critics, it is a model of government that
creates the global context for structural violence. Sometimes referred to as ‘market
fundamentalism’ or ‘laissez-faire,’ the model dictates an approach to government based on the
idea that capitalist social relations work best when they are liberalized from regulation and
organized on the basis of so-called free-market forces. The result of putting this idea into
governmental practice has been the emergence of a suite of policies that are now familiar right
around the world. The top ten most common of these neoliberal policies are:
1. free trade
2. privatization
3. deregulation
4. tax cuts
5. government spending cuts
6. efforts to reduce union power
7. efforts to attract foreign investment
8. efforts to reduce inflation
9. efforts to secure property rights
10. efforts to prioritize trade over aid
In addition to naming these specific sorts of policies, critics also tend to use neoliberalism to
refer to a more general emphasis on competition, individualism and entrepreneurial behavior in
social life. Scholars of the global political-economy document how these emphases come
together with the free market policies to create a system of governance shaping the actions of
governments and societies in even the most peripheral parts of the planet (see Gill, 2003; and
Tabb, 2004). Meanwhile critical theorists of western societies argue that the combination creates
structural violence in wealthy countries as well as poor ones (see Brennan 2003; Duggan, 2003;
and Giroux, 2004) .
To use ‘neoliberalism’ as a critical name for market fundamentalist policies and emphases is
confusing for US audiences because liberalism is commonly used in America to refer to a
welfarist concern for the marginalized. It needs to be explained therefore that the ‘neo’ does
mark something discrete and new historically: namely, the revival of classical 19th century free
market liberalism after and in opposition to the social-welfare liberalism of the mid-twentieth
century (Sparke, 2006). This revival of the ideas of older thinkers such as Adam Smith and
David Ricardo has been advocated and implemented in quite varied ways in different parts of the
world with the timing frequently related to particular periods of national economic crisis as well
as the ups and downs of business class power. Sometimes the process has been driven by
domestic policy elites advising political leaders that neoliberal reform offers the only way out of
crisis. Other times, especially in poorer parts of the world, it has been external experts from the
World Bank and International Monetary Fund who have forced national governments to accept
their so-called Washington Consensus on the need for neoliberal reforms. Poor countries’
governments have generally had to go along with the resulting calls for structural adjustment
of their economies (i.e. neoliberalization) because of their need for debt rescheduling after the
debt crises of the 1980s. And in yet other cases, violence and massive political changes –
including military coups in Latin America , the destruction of communism in Eastern Europe ,
and the capitalist remaking of communism in China – have led to especially coercive kinds of
neoliberal reform.
Notwithstanding the great variety of ways through which neoliberal policies have become
expanded and entrenched around the world, both advocates and critics alike agree that there have
been some fairly consistent results. Twentieth century ideas about comprehensive government
control over national economies have been increasingly abandoned. The class interests of
business elites have been consistently advanced. And almost everywhere policies of social
redistribution and nationally inclusive health, welfare and environmental protection, have been
subordinated to the competitive pressures of the global market. In place of the plural ‘freedoms’
once celebrated by twentieth century leaders such as the President Franklin Roosevelt – whose
famous ‘Four Freedoms’ included ‘Freedom From Want’ and ‘Freedom from Fear’ –
neoliberalism has thereby substituted the singular freedom of the ‘Free-market.’
In his very readable introduction to the topic, A Brief History of Neoliberalism, the geographer
David Harvey (2005) demonstrates persuasively that while the global neoliberalization process
has been geographically varied, the resulting consolidation of business class power has been a
consistent common denominator from one country to the next. Harvey argues critically that this
process of elite class consolidation has been paralleled by the removal and/or privatization of
public resources available to everybody else in society. He calls these parallel processes of
enrichment and impoverishment accumulation by dispossession. Many medical scholars have
sought to point to the same twin dynamics with titles such as Sickness and Wealth (Fort et al,
2004) and Dying for Growth (Kim, 2000). Less critical accounts reveal the same results,
although they also tend to make the TINA argument that there is simply no alternative, that freemarket liberalization represents the forward movement of history. This, for example, is the takehome message of an otherwise useful survey of the global variations in the timing and speed of
onset of neoliberal reforms presented by the American Public Broadcasting Service on
‘Commanding Height’ site (PBS, 2006). Countering the TINA-touts, however, critics in venues
ranging from the streets of Seattle, to the World Social Forum, to Trafalgar Square, to the
Lacandon jungle of Chiapas keep arguing that there are alternatives that will make another more
just and humane world possible. See, for example, the links from the web pages of the
International Forum on Globalization (IFG 2006), the World Social Forum (WSF, 2006) and
Global Exchange (GE, 2006).
As well as representing an ongoing controversy at the heart of public debates over globalization,
another reason for taking note of the competing discourses over neoliberalism is that it helps
provide a context for understanding Farmer’s critical comments about ‘cost efficacy’ in
Mountains Beyond Mountains. Behind this criticism are two key concerns. First, there is the
problem noted in various places through Mountains Beyond Mountains with the profiteering of
pharmaceutical companies making millions from drugs that ought to be free for the world’s poor
(see also Fort et al, 2004). And, second, there is Farmer’s outrage at the neoliberal premise that
care should be delivered only on a least cost, economic efficiency basis. “So we’ll give him a
couple of hundred dollars of Ensure, and I’ll take great pleasure in violating the principle of costefficacy” (Kidder, 2003: 25), he says in an aside reported near the start of the text. Likewise,
later on we hear about how he and Jim Kim seek to contest the talk of cost-effectiveness
altogether. “It often meant, ‘Be realistic.’ But it was usually uttered, Kim and Farmer felt,
without any recognition of how, in a given place, resources had come to be limited…. Strictly
speaking, all resources everywhere were limited, Farmer would say in speeches. Then he’d add,
‘But they’re less limited now than ever before in human history.’ That is, medicine now had the
tools for stopping many plagues, and no one could say there wasn’t enough money in the world
to pay for them” (Kidder, 2003: 175). Besides leading the Partners in Health team to label
international heath professionals TBMIs (‘transnational bureaucrats managing inequality’), this
critique also clearly has a basis in Farmer’s wider concerns with the violence of neoliberal
economic jargon itself: including its tendency to ignore suffering and squelch protests against
dispossession by presenting reform as simply technical and neutral. “[B]ullets are increasingly
unnecessary,” he says, “when defenders of social and economic rights are silenced by
technocrats who regard themselves as neutral” (Farmer, 2005: 10).
References
Bhagwati, J. 2004: In defense of globalization. Oxford: Oxford University Press.
Brennan, T. (2003) Globalization and its terrors: daily life in the West. New York: Routledge.
Duggan, L. (2003) The twilight of equality: neoliberalism, cultural politics and the attack on
democracy. Boston: Beacon Press.
Farmer, Paul (2005) Pathologies of Power: Health, Human Rights, and the New War on the
Poor, Berkeley: University of California Press.
El Fisgón, 2004, How to Succeed at Globalization: A Primer for the Roadside Vendor, New
York : Metropolitan Books.
Fort, M. Mercer, M. A. and Gish, O. eds. (2004) Sickness and wealth: the corporate assault on
global health, Cambridge , Mass. : South End Press.
GE, 2006, Global Exchange Homepage: http://www.globalexchange.org/
Gill, S. (2003) Power and resistance in the new world order. Basingstoke: Palgrave Macmillan.
Giroux, H. A. (2004) The terror of neoliberalism: authoritarianism and the eclipse of
democracy. Boulder, CO: Paradigm Publishers.
Harvey, D. (2005) A Brief History of Neoliberalism, Oxford: Oxford University Press.
IFG, 2006, International Forum on Globalization Homepage: http://www.ifg.org/
Kim, J. ed. (2000) Dying for growth: global inequality and the health of the poor, Monroe, Me.:
Common Courage Press.
PBS, 2006, ‘Commanding Heights’ at http://www.pbs.org/wgbh/commandingheights/hi/.html
Sparke, M. (2006) “Political Geographies of Globalization: (2) Governance,” Progress in Human
Geography 30, 2: 1 - 16.
Tabb, W.K. (2004) Economic governance in the age of globalization. New York: Columbia
University Press.
Wolf, M. 2004, Why globalization works. New Haven, CT: Yale University Press.
Matthew Sparke (sparke@u.washington.edu)
O for the P In the abbreviated lingo of the Partners in Health staffers, O for the P references the
‘preferential option for the poor’ philosophy that Paul Farmer pursues—itself an extension of his
quest for economic and social rights for all. The preferential option for the poor philosophy is
both informed and inspired by liberation theology, which in itself holds that the poor suffer
injustice and are severely exploited; the way to remediate this collective sin is to seek a
preferential option for the poor. Those interested in this topic should read chapter five of
Pathologies of Power, titled ‘Health, Healing, and Social Justice.’ Farmer insightfully remarks
that we should be further motivated by the fact that “diseases themselves make a preferential
option for the poor” (2005: 140). If we take seriously commitments like the Hippocratic Oath
and responsibilities as clinicians in the service of health, “medicine has a clear—if not always
observed—mandate to devote itself to populations struggling against poverty” (Farmer, 2005:
140). For Farmer, it is in service to the most destitute that the opportunities for advancement are
greatest and in which the moral statement to collective health is strongest. Farmer not-too-subtly
suggests that health technocrats, TBMIs, and their policies are antithetical to preferential options
for the poor (especially when constricted by ‘efficiency,’ ‘resource poor,’ or ‘appropriate
technology’ lines of reasoning). Farmer suggests that opportunities for change are abundant and
are of the most significance when we seek to serve the impoverished first through the simple yet
powerful observe, judge, act approach. Farmer not only gives lip service to the preferential
option for the poor philosophy—he acts on it by providing treatment regimens for individuals
suffering from MDRTB and AIDS/HIV, actions TBMIs would deem inappropriate and
ineffective; importantly, we see that in embodying this philosophy, community health outcomes
improve and through persistence paralyzing health crises can be addressed.
Reference
Farmer, P. (2005) Infections and Inequalities: The Modern Plague. Berkeley: University of
California Press.
Todd Faubion (tfaubion@u.washington.edu)
POLITICAL ECOLOGY OF DISEASE Kidder’s title of the book, which stems from the
Haitian proverb “Beyond mountains there are mountains,” may allude to his experience with
Farmer on their journey through the mountains to Morne Michel, the farthest settlement in
Zanmi Lasante’s catchment area (pp. 36-44). Although Kidder does not use the terms political
ecology or political ecology of disease to describe the population displacement and adverse
health consequences that have arisen from the creation of the seemingly beautiful dammed lake
there (Lac de Péligre), these terms are used within the disciplines of anthropology and geography
to interpret human-environment relations. These frameworks are not so much unified theories as
they are modes of explanations that fuse political economy with cultural ecology (and, in the
case of the political ecology of disease, disease ecology). In its explicit integration of the concept
of human agency, political ecology allows one to consider (or tease out) the effects of “‘hidden
agendas’ of individuals or groups in a political context, as well as the social forces and struggles
over resources and sociopolitical power” (Mayer 1996, p. 449). From its ecology heritage,
political ecology derives notions of “individual and group adaptation and adaptive processes,”
which are basic dimensions of human-environment interaction. Thus, with its blend of social and
material concepts and sciences, a political ecology research approach can offer an unparalleled
level of explanatory power into the nature and effects of ongoing struggles over natural resources
on planet Earth, both biotic and abiotic.
Since its inception, political ecology has been more widely applied to understanding the unequal
relationships within society to land-based resources in rural areas of developing countries
(Blaikie and Brookfield 1987). Traditionally, this mode of explanation has been used to uncover
the adverse consequences of development projects, such as land usurpation, environmental
degradation, and increased human vulnerability. More recent developments in the realm of
political ecology have incorporated critical, poststructuralist perspectives from areas such as
gender, cultural, and postcolonial studies (Peet and Watts 1996, 2004; Robbins 2004).
Additionally, within the past decade, there has been an emphasis on placing issues of disease and
health in conversation with political ecology forming the political ecology of disease and health
(Mayer 1996; 2006; Kalipeni and Oppong 1998; Baer 1996). Mayer, a chief advocate for the
political ecology of disease, identifies its two major features: locality and disease ecology. With
regards to the first, he observes it is a basic feature of political ecology in general and writes that
“the political ecology of disease…should demonstrate how large-scale social, economic and
political influences help to shape the structures and events of local areas” (1996, p.449). With
regards to disease ecology, the second major feature of a political ecology of disease approach,
Mayer recalls that disease ecology itself arose from the application of cultural ecology to the
study of human disease. Although disease ecology has traditionally been applied to infectious
diseases and diseases of malnutrition—many of which are endemic in poorer countries such as
Haiti—it can also be applied to other diseases, especially those that arise or are thought to arise,
in part or whole, from human interactions such as consumption (or lack of consumption),
absorption, or spatial coincidence, with environmentally-derived biological materials (e.g. plants,
high carbohydrate foods), chemicals and radiation (e.g. biotoxins, pollution), or spatiallydistributed violence and injury-causing objects and events (e.g., landmines, political/civil unrest,
unjust spatial confinement). Because of the wide applicability of disease ecology, a political
ecology of disease could therefore potentially address a large number of human diseases, both
infectious and non-infectious, that are thought to arise out of particular types of humanenvironment interaction. In a political ecology of health framework, environmental factors are
seen as having a very real and tangible impact on the embodied experience of health (for the sick
and hale alike) in a way that goes beyond physical exposures to disease-causing agents to how
large scale social forces affect local and embodied experiences of health and well-being. Critical
approaches to the political ecology of health and disease incorporate ever-broadening social,
political, economic, and cultural factors to challenge traditional causes, definitions, and
sociomedical understandings of disease.
In Kidder’s account of Morne Michel, we see that the hydroelectric dam is an example of a
development project similar to those later promoted by the World Bank and the IMF as part of
structural adjustment programs to attract foreign, transnational capital. Most Morne Michel
residents did not receive benefits from this dam built during the mid-1950’s; rather, they endured
negative consequences such as displacement, deepening poverty, and ill-health (pp. 37-38).
Moreover, they were forced to adapt to their new environment through out-migration to Haitian
urban areas, where many were exposed to HIV. Studies have also linked AIDS/HIV and other
infectious diseases such as schistosomiasis (a snail-borne parasitic disease) to the construction of
a hydroelectric dam in the Upper East Region of Ghana (Hunter 2003; Mayer 2005; Oppong
1998; Sauve et al. 2002). Researchers have applied the political ecology of disease framework to
a wide range of issues such as cryptosporidiosis in Wisconsin, Lyme disease in Connecticut, the
African refugee crisis, the global tuberculosis pandemic, landmines in Africa, the self-reported
health status of 'Namgis First Nation members affected by salmon aquaculture, land degradation
and disease ecology in Mozambique, deforestation and environmental health in southern Malawi,
polio resurgence in Africa, and flood hazard planning in Bangladesh. These are just a handful of
examples of how the political ecology of disease continues to be relevant for understanding
human-environmental relationships globally.
References
Baer HA. 1996. “Toward a Political Ecology of Health in Medical Anthropology.” Medical
Anthropology Quarterly 10(4): 451-454. (Refer to entire journal issue for further discussion.)
Blaikie P and Brookfield H. 1987. Land Degradation and Society. London: Methuen.
Hunter J. 2003. “Inherited burden of disease: agricultural dams and the persistence of bloody
urine (Schistosomiasis hematobium) in the Upper East Region of Ghana, 1959-1997.” Social
Science and Medicine 56: 219-234.
Kalipeni, E. and Oppong, J. 1998. “The refugee crisis in Africa and implications for health and
disease: a political ecology approach.” Social Science and Medicine 46(12):1637-53.
Mayer J. 1996. “The Political Ecology of Disease as a New Focus for Medical Geography.”
Progress in Human Geography, 20, pp. 441-456.
Mayer J. 2000. “Geography, ecology and emerging infectious diseases.” Social Science &
Medicine 50: 937-952.
Mayer J. 2005. “The geographical understanding of HIV/AIDS in sub-Saharan Africa.” Norsk
Geografisk Tidsskrift-Norwegian Journal of Geography 59:6-13.
Oppong JR. 1998. “A Vulnerability Interpretation of the Geography of HIV/AIDS in Ghana,
1986-1995.” Professional Geographer 50:4:438-448.
Peet and Watts. (eds.) 1996, 2004. Liberation Ecologies. London: Routledge.
Robbins P. 2004. Political ecology: a critical introduction. Malden, MA: Blackwell Pub.
Sauve N et al. 2002. “The Price of Development: HIV Infection in a Semiurban Community of
Ghana.” Journal of Acquired Immune Deficiency Syndromes 20:402-408.
Sunil Aggarwal (sunila@u.washington.edu)
Michelle Bilodeau (micheb3@u.washington.edu)
POLITICAL ECONOMY “To explain suffering,” Paul Farmer argues in his book Pathologies
of Power, “one must embed individual biography in the larger matrix of history, culture and
political-economy” (2005: 41). Used in this way, political economy basically describes an
understanding of economic forces that makes clear their deep interconnections with historical,
cultural and political processes. In other words, critics and commentators such as Farmer who
refer to political-economy generally advocate a historically and geographically materialist
approach to explaining economic forces that refuses to make the simplifying and often
mathematically-driven assumptions about economic behavior that are ever more common in
academic economics. While the formal models of such economics tend to assume individualistic,
competitive and market-driven behaviors as the norm of social relations, and while they also tend
to abstract away from real-world contexts with ‘how-many-angels-dancing on-the-head-of the
pin’ hypotheses about economic action, political-economy instead emphasizes examining how
economic processes actually unfold on the ground. As a result, it is an approach that is keenly
attuned to how political decisions and power relations both shape and get shaped by economic
patterns, and for the same reason it tends to be more politicized and change-oriented and it is
leftist critics who most frequently embrace the term. That said, political-economy is still very
broad and can be used by a wide range of scholars (from Marxists to conservative international
relations theorists) who in turn have a wide range of ways of understanding how power and
economics are intertwoven with one another on the global stage. To understand this variety it is
worth exploring a little of the history of the term political-economy before returning to how it is
used by critics of neoliberalism such as Paul Farmer. Originally, political-economy was a term
for the study of commodities and their relationship to laws, production, and government in the
developing capitalist system of 17th and 18th century England. It was used by both Adam Smith
and David Ricardo (the great grandfather of today’s mainstream economics), as well as by Karl
Marx whose most important work, the three volume explanation of capitalism’s inner workings
Capital, was subtitled, A Critique of Political Economy (Marx, 1977). Contrary to popular belief,
most of Marx’s writing were about understanding capitalism, not idealizing communism, and the
main point of his critique of the political-economy of Smith and Ricardo was that while it
developed a labor (as oppsed to land-) based theory of value it did not adequately come to terms
with the exploitative and thus power-ridden nature of the wage relations through which labor
became abstract value and thus the profit of business under capitalism. Subsequent to Marx a
great variety of theories of political economy have emerged. Anthropologists, sociologists and
geographers typically use the term “political economy” to refer to Marxian approaches to
development and underdevelopment.
References
Marx, K. 1977 Capital: A Critique of Political Economy, New York: Vintage.
Ricardo, D. 1821 On the Principles of Political Economy and Taxation, London: John Murray.
Amber Pearson (amberp37@u.washington.edu)
Matthew Sparke (sparke@u.washington.edu)
PRIVATIZATION This is the process by which assets or institutions that were formerly
publicly owned by governments in the name of their citizens are sold to corporations and
individuals. It has been one of the cornerstone policies of neoliberalism and has often allowed
neoliberal governments to follow their other policies of balanced budgets and fiscal conservatism
by providing them with one-time windfall profits. The problem is that having softened the initial
impacts of tax cuts and revenue reductions with such short term strategies, neoliberal politicians
do not have to explain that in the long term much deeper cuts in government services will be
required because of the lack of any further windfall privatization profits. Meanwhile, the actual
consequences of privatization have been uneven at best and, more often, devastating. In rich
countries the disaster of rail privatization in the UK stands as a powerful example of the deaths,
delays and knock-on economic drag that privatization can have on an economy. And in the
Global South the example of the privatization of water in countries such as Bolivia has not only
led to shortages, but also more death, disease, huge political upheaval and widespread chaos.
Here is how the writer Arundhati Roy describes the more general problem:
What does privatization mean? Essentially, it is the transfer of productive public assets from the
state to private companies. Productive assets include natural resources. Earth, forest, water, air.
These are assets that the state holds in trust for the people it represents. In a country like India,
seventy per cent of the population lives in rural areas. That’s seven hundred million people.
Their lives depend directly on access to natural resources. To snatch these away and sell them as
stock to private companies is a process of barbaric dispossession on a scale that has no parallel in
history (Roy, 2001: 43).
Reference
Roy , A. (2001). Power Politics. Cambridge, MA: South End Press.
Matthew Sparke (sparke@u.washington.edu)
PROPHYLAXIS Colloquially, this term is associated with forms of contraceptives such as
condoms and birth control. The literal meaning of prophylaxis, however, is to guard or prevent
beforehand. Prophylaxis can be applied to any public health measure to prevent disease or
infection. Early examples of prophylactic public health and medical measures include the
development of vaccines, quarantine, and the implementation of sanitation regulations to
eliminate solid and liquid waste.
Vaccines are prophylactic in that they prevent disease by exposing individuals to a small quantity
of a pathogenic organism usually through an injection, or vaccination. By receiving a
vaccination, an individual builds immunity to a particular pathogenic organism and the
likelihood that a person will become infected by this pathogen is greatly reduced. One of the first
vaccines developed was for smallpox virus. Smallpox vaccinations proved effective in
diminishing this deadly virus. After an eleven year campaign taken on by the World Health
Organization, smallpox was officially declared as a worldwide eradicated disease in 1980
(Garrett 1994).
Improved sanitation is probably the most notable form of prophylaxis. During the late nineteenth
century, both the United States and in other industrializing nations realized that by eliminating
sewage and garbage from cities improved living conditions, disease morbidity and mortality
decreased.
The development of infrastructure for sanitation requires political will and effective public health
systems. Haiti lacks any continuous infrastructure for sanitation removal and potable water
supply in addition to basic health care services. Kidder includes the quote from Rudolf Virchow
(pp. 61) in which Virchow states, “My politics were those of prophylaxis, my opponents
preferred those of palliation,” to emphasize that reducing disease in developing countries calls
for preventing illness through equal access to health care as opposed to ineffectively managing
symptoms of disease.
Although a primary mission of Partners in Health (PIH) is “to bring the benefits of modern
medical science to those most in need of them and to serve as an antidote to despair” (PIH
website 2005), another is to prevent infectious and non-infectious disease through prophylactic
measures such as immunizations, nutrition, preventative health care, and education. Within
Kidder’s biography, numerous examples of Farmer and others providing prophylactic care are
interspersed throughout the book. For instance, the improvements made (pp. 107) by Zanmi
Lasante and others to the residents’ homes in Cange are examples of a prophylactic measures to
prevent infectious diseases. By reducing the presence of vectors that can enter the dwelling and
by creating additions to homes of larger families, transmission of infectious diseases such as
malaria and TB may be reduced.
As an aside, the term prophylaxis only became connected to the prevention of sexual
reproduction and transmission of sexually transmitted diseases (STDs) at the beginning of the
twentieth century with such movements as the Society for Sanitary and Moral Prophylaxis
(Morrow 1907; Luker 1998). This movement attempted to educate people about measures they
should take to prevent sexually transmitted diseases like syphilis and other STDs. Ultimately,
however, the Society Sanitary and Moral Prophylaxis failed because it equivocally addressed
how STDs were transmitted and was moralistically charged. Much of the education regarding the
transmission of HIV/AIDS in developing countries remains connected to moralistic attitudes
surrounding sexual relationships, and often emphasizes abstinence and faithfulness as
prophylactic measures to safeguard against AIDS/HIV and other STDs rather than using
condoms or the empowerment of women to be able to negotiate sexual relationships (Kalipeni et
al. 2004).
Prophylaxis, and more broadly, prevention is always the best approach to medicine. While health
prevention and use of prophylactic measures such as immunizations may appear to be more
costly, the prevention of disease is not only less expensive over the long-run, but it can also save
countless lives.
References
Garrett, L. (1994) The Coming Plague. New York, New York: Penguin Books.
Kalipeni, E., Craddock. S., Oppong, J.R., and Ghosh, J. (2004) HIV & AIDS in Africa: Beyond
Epidemiology . Malden, Massachusetts: Blackwell Publishing.
Kidder, T. (2003) Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who
Would Save the World, New York: Random House.
Luker, K. (1998) “Sex, social hygiene, and the state: The double-edged sword of social reform”
Theory and Society 27:5:601-634.
Morrow, P. (1907) “Prophylaxis of Social Diseases” The American Journal of Sociology
13:1:20-33.
Partners in Health (2005) http://www.pih.org/whoweare/.html
Michelle Bilodeau (micheb3@u.washington.edu)
PUBLIC HEALTH Public health is the name of the discipline that aims to protect the physical
and mental health and well-being of populations. The emphasis on health of the population
versus the individual is the core distinction between the fields of public health and medicine.
Public health efforts are largely composed of prevention and surveillance programs, as in the
prevention of disease or illness through vaccination/immunization campaigns (i.e. small-pox
prophylaxis) or early detection and treatment of cases through surveillance activities. Other
examples of typical public health campaigns involve hygiene promotion, development of
sanitation infrastructure, and healthy behavior initiatives.
For governments, public health efforts are challenging because the investment in public health
activities is laden with conflicts around cost-effectiveness and efficacy. Most countries’ public
health agencies are under-funded. This is especially true in indebted countries as external lending
agencies imposed neoliberal, privatization policy measures on governments. Such measures
have forced reallocation of public health funds to projects such as transportation infrastructure,
or the promotion of particular types of commercial agriculture. In response to criticisms that
reveal how those policy measures lead to failed development efforts, many current lending
schemes reverse the promotion of fiscal austerity and may now require governments to retain
existing national budget funds allocated to public health activities.
Despite this response, substantial rifts in public health services emerged after years of health
services neglect. These gaps in public health are common targets for NGOs as international
development agencies fund projects (usually designed by the donor country with the funders’
aims in mind) to improve global health. Often, the result is that governments come to rely on
international NGOs to provide those essential public health initiatives. This cycle functions
alongside the privatisation of health care in general and increased self-governance and ideas of
responsibility of self rather than social and community service provision. Dependence upon
NGOs to provide basic human services may further increase the unwillingness or hamstring the
ability the nation-state to provide services.
Farmer turns the classic notion of public health on its ear as he delivers both medical treatment
and public health services to the population of Cange. Public health is normally concerned with
prevention of disease as such measures are largely more cost-effective then treating an entire
population for a disease. Through Farmer’s political economic analysis, we see that he rejects the
parsimonious status quo; funds and resources are available, but are directed to privileged
populations. As a result, his position is that both treatment and prevention are public health
services, as the resources do exist and both treatment and prevention efforts are enhanced by one
another.
Currently, AIDS/HIV treatment efforts funded by branches of the WHO and the US State
Department are underway in those countries hardest hit by the pandemic, as the idea of public
health is evolving from a perspective limited to prevention campaigns to one that recognizes the
synergistic effects of treatment in combination with prevention.
Sarah Paige (spaige2@u.washington.edu)
SOCIAL DETERMINANTS OF HEALTH The idea that physical health can be affected by
social conditions is not new. Although almost everyone gets sick from time to time, as the WHO
points out, “poorer people live shorter lives and are more often ill than the rich.” Illness and
disease are worse, in general, when people live in more crowded, stressful environments, have
less education or social supports, are unemployed, or feel excluded from society. The term
“social determinants of health” has been used by Richard Wilkinson and Michael Marmot
(1999/2005) and is now the title of a World Health Organization Commission, started in 2005,
aimed at improving health by improving social conditions (see WTO, 2006). The phrase
highlights the link between poverty and health, also called the “social gradient in health”, “health
disparity” in the US, and “health inequalities” in Europe and the UK.
References
Marmot M, Wilkinson RG, editors, 1999, Social Determinants of Health Oxford: Oxford
University Press, (second edition 2005).
http://www.doh.wa.gov/HWS/doc/RPF/RPF_soc.doc for an article about this topic from the
Washington State Department of Health.
WTO, 2006, http://www.who.int/social_determinants/en/
Jane Huntington (janehh@u.washington.edu)
SOCIAL MEDICINE an approach to medicine based on the interaction of health, disease, and
social relations. The practice of medicine and the experience/existence of disease are profoundly
impacted by social, cultural, political, and economic conditions such that we can never simply
consider the biology or pathology of a disease when examining the population it strikes, its
geographical range, or its severity. Rather, we must consider society, culture, politics, and the
economy as all broadly causing disease and illness. The most acute threats to human health faced
today are treatable/preventable with the appropriate interventions; therefore, the existence and
spread of disease is mediated by conditions external to the body. Consider, for instance, that
malaria was once endemic to much of the developed world—including the United States —but
has been eradicated through public health measures. HIV does not have a biological attraction
to the continent of Africa save vast poverty, poor healthcare, and fractured social relations, to
name a few human-driven factors. Likewise, tuberculosis flourishes in settings of poverty where
people do not have access to adequate medical care and living conditions lack adequate space
and ventilation. Farmer quotes René Dubos: “Tuberculosis is a social disease, and presents
problems that transcend the conventional medical approach…Its understanding demands that the
impact of social and economic factors on the individual be considered as much as the
mechanisms by which tubercle bacilli cause damage to the human body” (1999: 228). As Farmer
eloquently states, “One place for diseases like tuberculosis to ‘hide’ is among poor people,
especially when the poor are socially and medically segregated from those whose deaths might
be considered more significant” (1999: 187). If we take seriously the idea that health is socially
mediated, then our actions to remediate health crises need to extend far beyond the sphere of
biomedical interventions; we must undo structural violence, erode inequality, agree to basic
human rights, etc. Biomedicine (antibiotics at the doctor for an infection, surgery for a malignant
tumor, medicine to treat STD’s, etc.) does not dominate the healthcare delivery paradigm under
the social medicine school of thought; rather this concept mandates equal engagement with
human-driven forces that create conditions ripe for illness. Two further crucial elements of social
medicine are that the health of a population is a social (collective) concern and that societies
should promote both individual and collective health (SMP, 2005). In the absence of a social
commitment to health, inequality flourishes and radically divergent health outcomes emerge the
world over. In the United States, where healthcare has been for the large part commodified by
private insurance companies, we see an acute example of this type of inequality. It is estimated
that upwards of fifty million Americans have no health insurance; this is why the United States
ranked 29 of 30 in the Health Olympics ranking sponsored by the Population Health forum at the
University of Washington (http://depts.washington.edu/eqhlth/). While the United States is the
uncontested leader in pioneering life-saving technology (for those who can afford it), the huge
advances in biomedical science are meaningless to those who cannot access them (the majority
world). Paul Farmer is a strong advocate for the concept of social medicine, teaching its
principles at Harvard and using it as a conceptual and theoretical tool to encourage the reduction
of inequality and a commitment to collective well-being
(http://www.brighamandwomens.org/socialmedicine/).
References
Farmer, P. (1999) Infections and Inequalities: The Modern Plagues, Berkeley: University of
California Press.
School of Public Health and Community Medicine. (2003) Population Health Forum, Seattle:
University of Washington. http://depts.washington.edu/eqhlth/
Social Medicine Portal. (2005). http://www.socialmedicine.org/newtosm.html
Suggested Courses
ANTH 474 Social Difference and Medical Knowledge (5) I&S Taylor
Explores relations between medical and social categories: how social differences become
medicalized; how medical conditions become associated with stigmatized social groups; and
how categories become sources of identity and bases for political action. Considers
classifications (race, gender, sexuality, disability) and how each has shaped and/or been shaped
by medical science/practice
ANTH 475 Perspectives in Medical Anthropology (5) I&S
Introduction to medical anthropology. Explores the relationships among culture, society, and
medicine. Examples from Western medicine as well as from other medical systems,
incorporating both interpretive and critical approaches. Offered: jointly with HSERV 475.
ANTH 476 Culture, Medicine, and the Body (5) I&S
Explores the relationship between the body and society, with emphasis on the role of medicine as
a mediator between them. Case study material, primarily from contemporary bio-medicine, as
well as critical, postmodern, and feminist approaches to the body introduced within a general
comparative and anthropological framework.
GEOG 280 Introduction to the Geography of Health and Healthcare (5)
Concepts of health from a geographical viewpoint, including human-environment relations,
development, geographical patterns of disease, and health systems in developed and developing
countries.
GEOG 380 Geographical Patterns of Health and Disease (4)
Geography of infectious and chronic diseases at local, national, and international scales;
environmental, cultural, and social explanations of those variations; comparative aspects of
health systems.
GEOG 480 Environmental Geography, Climate, and Health (5)
Demonstrates and investigates how human-environment relations are expressed in the context of
health and disease. Local and global examples emphasize the ways medical geography is situated
at the intersection of the social, physical, and biological sciences. Examines interactions between
individual health, public health, and social, biological, and physical phenomena.
HUM 201 Diagnosing Injustice: Ethics, Power and Global Health (5) Taylor & Goering.
Surveys the problem of global health disparities, and connections between power and health.
Introduces conceptual tools from medical anthropology and medical ethics for critically
analyzing health and illness in global, social, and ethical perspectives. Topics include poverty
and structural violence, war and terror, biotechnology and pharmaceuticals.
Todd Faubion (tfaubion@u.washington.edu)
STRUCTURAL ADJUSTMENT PROGRAMS Structural adjustment programs, or SAPs, are
the official name for the enforced neoliberalism (i.e. free market policy reforms) imposed on
developing countries by international financial institutions such as the World Bank and the IMF
as a condition for new loans or debt rescheduling. The supposed purpose of such programs is to
make states more competitive and therefore better able to pay off their debt with the revenue
generated by economic growth. Being more competitive in this market-based sense also means
sharply cutting various social programs, including all kinds of investment in education, healthcare and even the infrastructural development of roads, running water and sewage treatment. In
practice, this kind of fiscal austerity has only undermined economic performance. All of the
indebted countries have remained deeply indebted, with 41 countries now considered as HIPCs
(Highly Indebted Poor Countries). Thirty-three of these 41 paid $3 in debt service payments to
the Global North for every $1 in development aid. Many also continue to pay over 50 percent of
their government revenues toward debt service.
Haiti’s history is totally bound up with debt. Beginning with France’s demand for a hefty
remuneration in exchange for recognition of Haiti’s independence, Haiti’s debt has been a huge
burden ever since sovereignty (Jubilee 2006). Consequentially, Haiti has been unable to invest in
public infrastructure such as schools, roads, and health care, and is now considered the poorest
country in the Western hemisphere. Throughout his biography of Farmer’s life and his
experiences working in Haiti, Kidder recounts how the Duvalier era has contributed greatly to
the economic and political strife Haitians’ continually encounter (Kidder, 2003: 73, 97, 104105). The corrupt father-son (“Papa Doc” and “Baby Doc” Duvalier) dictatorship that controlled
Haiti for almost thirty years resulted in the misappropriation of millions of dollars, political and
economic unrest, and the exacerbation of Haiti’s external debt (Jubilee 2006). Because of “Baby
Doc’s” blatant embezzlement of state funds and foreign aid assistance for his own personal use
during the 1980s, some foreign aid was curtailed (Haggard 1985). Haitians did not receive any
benefit of foreign assistance during the Duvalier era; life for Haitians during this time period
only equated to a deepening sense of poverty. Haiti entered into its first structural adjustment
program with the IMF and the World Bank in 1986 in conjunction with Duvalier’s ousting from
office. As Kidder iterates (pp. 105), following “Baby Doc’s” removal from office, Haiti was
embedded within “the tumble” of political turmoil and extreme civil violence. The rapid
economic liberalization derived from these SAP agreements has added to Haiti’s tumultuous
state because of the lack of necessary price controls and an unstable exchange rate.
Unemployment and urbanization have increased along with further degradation to the
environment (primarily through the increase of debilitating cash-cropping agricultural practices)
(McGuigan 2006). A second SAP agreement was implemented in 1994 under Aristide’s
leadership. Although Aristide advocated for economic reforms which included a higher
minimum wage and imposing price controls for food products, “his pro-poor economic stance
was not well received by the international financial institutions and bilateral donors” (McGuigan
2006). As of 2005, Haiti has a current external debt of $1.3 billion and over 80 percent of
Haitians live in abject poverty (Jubilee 2006; World Bank 2000). Yet, Haiti was not considered a
HIPC until April of 2006 because it failed to meet the three criteria for debt relief assistance
under the HIPC program (ibid). Although Haiti is now considered a HIPC, the country will not
be able to cancel any debt until 2009, and a large proportion of Haiti’s debt (which is owed to the
International American Development Bank) is excluded for the country’s total external debt
(Jubilee 2006). In the meantime, improvements in health care, education and other social
services are left by the wayside as money must be allocated towards debt repayment. Unless
Haiti’s debt can be cancelled, the country’s development will continue to be underscored by
poverty and poor public health.
References
Haggard, S. (1985) “The Politics of Adjustment: Lessons from the IMF’s Extended Fund
Facility” International Organization 39(3): 505-534.
Jubilee USA Network (2006). “Fact Sheet: Haiti’s Debt”
http://www.jubileeusa.org/take_action/haitifact06.pdf
McGuigan, C. (2006) “Agricultural liberalization in Haiti” Christian Aid Report
http://www.haitisupport.gn.apc.org/Haiti_Agricultural_Liberalisation_Report.pdf
The World Bank Group (2000) “Haiti and the Heavily Indebted Poor Countries Debt Relief
Initiative” http://lnweb18.worldbank.org/External/lac/lac.nsf/Countries/Haiti/
Michelle Bilodeau (micheb3@u.washington.edu)
Matthew Sparke (sparke@u.washington.edu)
STRUCTURAL VIOLENCE A term used by Paul Farmer and other critics of global injustice
to describe economic, political and cultural dynamics that work systematically through social
structures to create human suffering. It is ‘structural’ in the sense that the suffering is not
produced by direct one-on-one acts of violence such as spousal abuse, lynching or torture –
although even these kinds of inter-personal violence are clearly tied to social structures
(including patriarchy, white supremacy and militarism) that extend beyond the individuals
involved. Structural violence is still less personal, intentional and direct “[s]ince the misery in
question need not involve bullets, knives, or implements of torture” (Farmer, 2005: 8). It
involves more mediated and multi-factor forms of oppression in which sexism, racism,
homophobia and other forms of social pathology frequently come together with economic
exploitation and deprivation. For Farmer it is therefore “a broad rubric that includes a host of
offenses against human dignity … ranging from racism to gender inequality… [to] extreme and
relative poverty” (Farmer, 2005: 8). He cautions against economic reductionism (i.e. explaining
everything in terms of economic dynamics), but it is nevertheless clear that he thinks “the
world’s poor are the chief victims of structural violence” (2005: 50). It is in turn his driving
concern to explain poverty as a kind of generalized ‘coinfection’ creating the context for disease
that accounts for why Farmer frequently talks about structural violence as if it operated like an
unseen virus destroying a patient’s immune system (Farmer, 1999). While the visible hands of
abusive husbands, white supremacists and military interrogators all go on producing suffering,
Farmer emphasizes thus that structural violence more generally involves invisible hands that
produce global inequality through transnational political-economic processes.
References
Farmer, Paul. (1999). Infections and inequalities: the modern plagues. Berkeley: University of
California Press .
Farmer, Paul. (2005). Pathologies of Power: Health, Human Rights, and the New War on the
Poor. Berkeley: University of California Press.
Matthew Sparke (sparke@u.washington.edu)
TB see MDR-TB
TBMI Another one of the in-house Partners in Health acronyms introduced by Kidder, TBMI
stands for Transnational Bureaucrats Managing Inequality. As such, it is a term that conveys the
concerns of Paul Farmer and Jim Kim with the uncaring, depoliticized, and largely economistic
approaches to global health perpetuated by the institutions most closely associated with
enforcing the free-market development policies of neoliberalism. Their critique extends from
the World Bank and IMF to the cost efficacy approach to global health perpetuated by some
(although by no means all) of the managers at the World Health Organization (WHO). More
abstractly, the idea of transnational bureaucrats merely managing (rather than challenging)
inequality links to Farmer’s wider concerns about the violence of neoliberal economic jargon
itself. For Farmer this violence includes the way the economic jargon tends to ignore suffering
and squelch protests against dispossession by presenting reform as simply technical and neutral.
“[B]ullets are increasingly unnecessary,” he says, “when defenders of social and economic rights
are silenced by technocrats who regard themselves as neutral” (Farmer, 2005: 10). It is just such
technocrats that the Partners in Health group refer to as TBMI. A 2006 story in the Financial
Times concerning US government efforts to curtail the production of cheap generic drugs
provides some classic examples of the genre. The story concerned a WHO official called
William Aldis who raised concerns in a Bangkok newspaper about how a bilateral free trade deal
between the US and Thailand would jeopardize the ability of the Thai government’s
pharmaceutical organization to provide generic second line anti-retrovirals (drugs that are
increasingly needed in treatment of the over half a million Thais living with AIDS/HIV). The
Financial Times reported that the article by Mr. Aldis so upset US officials that the head of the
American delegation to the United Nations in Geneva, Kevin Moley, forced the WHO directorgeneral Lee Jong-Wook to have him abruptly moved out of his job (Kazmin, et al, 2006). In the
technocratic speak of a US official interviewed by the reporters, the problem was simply that a
WHO official had spoken out of turn: “For someone on the WHO payroll to criticize a bilateral
negotiation is not appropriate.” But in the language of Partners in Health, the real crime of Mr.
Aldis was that he wasn’t properly acting like a TBMI. Instead, he was refusing to stand by and
manage an obvious inequality in US-Thai negotiating power that would lead to improved profits
for US pharmaceutical firms and increased deaths for Thais living with HIV. It was for this,
notably non-TBMI, behaviour he ended-up being moved out of his job. Meanwhile Mr. Moley’s
work as a committed TBMI has recently extended to defending the US government’s uneven
record on torture (ie managing the violent inequality between torturing prisoners and refusing to
abide by the Geneva Conventions in places such as Guantanamo and Abu Ghraib while claiming
to be against torture).
References
Farmer, P. (2005) Pathologies of Power: Health, Human Rights, and the New War on the Poor,
Berkeley: University of California Press.
Kazmin, A. et al (2006) “Patent or patient? How Washington uses trade deals to protect drugs,”
Financial Times, August 22, page 9.
Matthew Sparke (sparke@u.washington.edu)
TYPHOID Typhoid, or typhoid fever, is an illness caused by infection with the bacterium
Salmonella typhi and spread through fecal-oral contact. A person infected with typhoid carries
the bacterium in their blood and intestinal tract; typical signs and symptoms include prolonged
fever as high as 103°-104°F, weakness, stomach pains, headache, loss of appetite, and
occasionally a spotty, rose-colored rash. Stool or blood tests are performed to confirm the
diagnosis. The infection is treatable with antibiotics and can be fatal if untreated. A mild or
asymptomatic carrier state of typhoid can exist. The first ‘healthy carrier’ of typhoid was
discovered in 1907 in New York City. Known colloquially as ‘Typhoid Mary’, Irish-American
immigrant Mary Mallon is believed to have been inadvertently responsible for over 200 cases of
typhoid fever due to her shedding of the infectious agent in the course of her work as a cook.
Public health authorities coerced Mallon to be quarantined and to submit to laboratory testing.
Her case raised important questions about the uneasy balance between public health and social
control. Annually, approximately 22 million typhoid cases develop worldwide with
approximately 200,000 of these resulting in death. Typhoid fever commonly occurs in most parts
of the world except in industrialized regions such as the United States, Canada, Western Europe,
Australia, and Japan where publicly-funded water and food distribution sanitation systems are in
place. Poorer countries, often due to conditions of structural violence, lack the funds necessary
to build and maintain robust sanitation infrastructure. The risk of acquiring typhoid may be
decreased by inoculation with one of the two available vaccines on the market, but these are
economically accessible only for the wealthy. The illness is called ‘typhoid’ because it was
formerly believed to be a variety of typhus, which is now known to be a distinct febrile
infectious disease transmitted by lice or fleas due to the bacteria Rickettsia prowazekii and
Rickettsia typhi.
References
“Typhoid Fever.” CDC: Centers for Disease Control and Prevention. (Available online:
http://www.cdc.gov/NCIDOD/DBMD/diseaseinfo/typhoidfever_g.htm, accessed 7/24/06).
“Typhoid.” Oxford English Dictionary
“Typhus.” Medline Plus Medical Encyclopedia. (Available online:
http://www.nlm.nih.gov/medlineplus/ency/article/001363.htm, accessed 7/24/06)
Wald P. 1997. “Cultures and Carriers: 'Typhoid Mary' and the Science of Social Control.” Social
Text 52-53:181-214.
Sunil Aggarwal (sunila@u.washington.edu)
WASHINGTON CONSENSUS The Washington Consensus (henceforth WC) was a 1990s
name for neoliberalism that underlined the connections between free-market reforms and the
controlling interests of the government of the United States and Washington DC-based
international financial institutions (including the IMF and World Bank). The term remains a
useful complement to neoliberalism insofar as it clearly draws attention to this controlling
American role and the resulting asymmetries in global governance. However, the initial
development of the WC as a term owed less to critics of American imperialism and more to
neoliberal academic insiders operating within the so-called ‘Beltway’ in Washington, D.C. One
of its most authoritative academic proponents, John Williamson (a senior fellow at the DC based
Institute for International Economics), argued in this way that the WC comprised an acceptance
of the following nine policy norms: 1) fiscal austerity; 2) reduced public spending (to help with
the fiscal discipline); 3) reduction and flattening of tax rates; 4) market-set interest rates that are
positive and real in order to reward the owners of money; 5) competitive but non-inflationary
exchange rates; 6) trade liberalization; 7) encouragement of foreign direct investment (FDI); 8)
privatization; and 9) secure property rights. In 1993 Williamson maintained that any criticism of
this “common core of wisdom embraced by all serious economists” could only come from
cranks, and went on to note that: “The proof may not be quite as conclusive as the proof that the
Earth is not flat, but it is sufficiently well established to give sensible people better things to do
with their time than to challenge its veracity” (Williamson, 1993: 1330).
As the 1990s rolled on the WC as it was understood in key Washington institutions such as the
World Bank began to lose credibility. Important leaders at the Bank including Ravi Kanbar (an
economist from Cornell University) began to defect from the consensus with calls for more
emphasis on policies of social redistribution. In 2000, the crisis had developed so far that a
leading neoliberal magazine even spoke of a new ‘Washington Dissensus’ (The Economist,
2000). By this point the WC had been rocked both by a debate over the successes of the so-called
Tiger economies (Taiwan, Singapore, Hong Kong and South Korea), as well as by the failures of
the 1997 Asian financial crash. In both cases the supposed consensus over neoliberalism was
challenged: first by the argument that the Tigers had grown so much because of non-neoliberal
policies of strong state support for industrial development; and second, by observations that the
states that weathered the 1997 crisis the best were the ones who refused to do what the IMF and
World Bank were recommending. Development geographer Gillian Hart notes that:
As the financial crisis deepened, there were key defections from the WC. For example, Jeffrey
Sachs (until then, a prominent IMF consultant) alleged that ‘instead of dousing the flames, the
IMF screamed fire in the theater’. At around the same time Joseph Stiglitz (then senior vice
president and chief economist at the World Bank) delivered his famous ‘post-Washington
consensus’ speech to the World Institute for Development Economics Research in Helsinki in
which he asserted that financial market liberalization had contributed to instability, and called for
a reversal of neoliberal orthodoxy. (Hart, 2001: 653)
Subsequently, Joseph Stieglitz (2002) continued the questioning in his book Globalization and
its Discontents, but it is not yet clear whether a post-Washington consensus is forming. Clearly,
the World Bank is making many more noises about the need for social investment, state aid, and
sustainable development, but the IMF continues on its old WC tracks. It is perhaps the Genevabased WTO that holds the greatest potential for creating a new post-Washington Consensus
insofar as it is proving an important venue for poor country complaints about US farm subsidies.
These complaints may yet have some affect in displacing Washington’s ability to uphold huge
global asymmetries in world trade. But even if they do, the new consensus will still be
neoliberal, and many of its leading thinkers and promoters will still be based in Washington.
References
The Economist. (2000).“The Washington Dissensus,” accessed at
http://www.economist.com/display/Story.cfm?story_ID=81411
Hart, G. “Development critiques in the 1990s: culs de sac and promising paths,” Progress in
Human Geography 25,4 (2001) pp. 649–658.
Stieglitz, J. (2002) Globalization and its discontents. New York: Norton.
Williamson, J. “Democracy and the Washington consensus,” World Development 21(8) 1993,
1329–36.