It has been well understood for some time now that COVID-19 and its ensuing global pandemic are unprecedented events in our contemporary world. Not since the Influenza Pandemic of 1918 has global life been so drastically altered so quickly due to a viral outbreak.
In the century since 1918, countless individuals, organizations, and nations have striven to eradicate the unnumbered diseases, parasites, and structural barriers that cause unnecessary death, needless suffering, and the squandering of human potential.
Paul Farmer is one of those individuals. Chair of the Department of Global Health and Social Medicine at Harvard Medical School, Farmer is co-founder of Partners in Health, serves as a Special Advisor to the United Nations, and has authored several books on the topics of global health, human rights, and international cooperation.
Given our aforementioned collective moment in history, UC Press would like to bring renewed attention to these topics and Farmer’s role as a leading public figure.
The following is an excerpt from the conclusion of AIDS and Accusation: Haiti and the Geography of Blame (2006).
Throughout the world, but particularly in what is termed the “Third World,” much of human suffering is caused or aggravated by social forces, and social forces should be studied by medical anthropologists. Suffering is a legitimate subject of ethnographic investigations, with important intellectual and ethical provisos. One of these provisos, as stated at the outset, is that the lived experience of the disorder is paramount.
A second is that, when the subject is sickness, epidemiology should be another component of responsible materialism. Although repeatedly termed a “complete mystery” by North American academics, the epidemiology of AIDS and its silently transmitted precursor, HIV, is only superficially random. Careful review of existing data and critical assessment of the validity of certain studies allow us to conclude that the Haitian epidemic is a tragic but unsurprising component of a much larger pandemic. In the various theaters of this international scourge, whether New York or Port-au-Prince, HIV has become what Sabatier (1988) has termed a “misery-seeking missile.” It has spread along the paths of least resistance, rapidly becoming a disorder disproportionately striking the poor and vulnerable.
Much is made in the public health literature of the similarities between the Haitian and the African AIDS epidemics, but the Caribbean epidemic is of this hemisphere. Current understandings of the epidemiology of HIV in the region suggest that the virus came to the Dominican Republic, Jamaica, Trinidad and Tobago, and the Bahamas in a manner similar to that documented in Haiti-from the United States, and perhaps especially through tourism. Caribbean tourism stands increasingly as an index of dependence on North America. This trade is also emblematic of the striking economic disparity between the poor periphery and the. rich center. 5 The relation between the degree of “insertion” in the West Atlantic system and prevalence of AIDS was suggested by an exercise comparing AIDS attack rates to U.S.-Caribbean trade indices reflecting involvement in the West Atlantic system. The five countries with the largest number of cases by 1986 were as follows: the Dominican Republic, the Bahamas, Trinidad/Tobago, Mexico, and Haiti. In terms of exports, which are the five countries most dependent on the United States? In both 1983 and 1977, the same five countries held that honor-precisely those with the largest number of cases of AIDS. Haiti, the country with the most cases, is also the most economically dependent vis-a-vis the United States.
But it is unnecessary to posit a causal link based on mere association with trade patterns. In several of these countries, at the outset of the epidemic, seropositivity to HIV was correlated most strongly with a history of sexual contact with North Americans. For this and other reasons, it was suggested, the terminology deployed by the World Health Organization’s Global Program on AIDS is somewhat obscurantist. The epidemiology of AIDS in the Caribbean is described as ”Pattern II,” as it is in sub-Saharan Africa. Pattern II is held to differ from Pattern I, seen in North America and Europe, “in that heterosexual intercourse has been the dominant mode of HIV transmission from the start. Blood transfusion, the reuse of contaminated needles, and intravenous drug use contribute to a variable degree, but homosexuality generally plays a minor role in this pattern” (Osborn 1989:126). And yet what is known of “the start” of AIDS in the Caribbean suggests that the epidemics there were introduced through international prostitution, same-sex sexual contacts, and bisexuality. Blood tranfusion also played a role. These island epidemics are not in all likelihood “direct descendants” of the African pandemic. They are American.
A historical understanding of the worldwide spread of HIV is of some significance, and I have attempted to postulate the trajectory of the virus in the Caribbean basin. Leibowitch (1985:57) offers a speculative history of another retrovirus, HTLV, which is endemic to parts of the Caribbean: “The map of HTLV in the New World is that of the African diaspora.” Because that “diaspora” refers to the massive dislocations of Africans through the slave trade, another way of phrasing this would be that the map of HrL V in the New World is the map of European imperial expansion. Given that unequal relations between the Caribbean and North America have contributed to the current epidemiology of HIV, an analogous exercise leads to a somewhat analogous observation: the map of HIV in the New World reflects to an important degree the geography of U.S. neocolonialism.
Recourse to crude formulations-for example, “imperialism causes AIDS”-is unnecessary. But exhaustive exploration of AIDS as a “sent sickness,” when conducted in tandem with careful study of the local epidemiology of HIV, emboldens us at least to discuss important correlations such as those made above. That such considerations have been important in the lineaments of the American epidemics is suggested by comparing Haiti with Cuba, where only 0.01 percent of persons tested were found to have antibodies to HIV. In most other parts of the Caribbean, seroprevalence among apparently healthy urban adults is two to three orders of magnitude higher than that registered in Cuba. As noted in chapter 14, the fact that HIV made its advent in the last decades of the century, rather than earlier, determined to no small extent the spread of HIV infection in the Caribbean.
Such assertions are a long way from the meaning-laden realm of sexuality, an understanding of which is necessary for a thorough understanding of the world AIDS pandemic. But here too it is impossible for long to steer clear of the hard surfaces of life. Here are the observations of Dr. Bernard Liautaud, who in 1979 identified the first documented case of Kaposi’s sarcoma in a Haitian: “There are two groups of homosexuals. There are those who do it for pleasure and those who do it for economic reasons. In Haiti, we have economic homosexuals: poor people making love for money.”6 Certainly, the formula is simplistic. And yet it reminds us that few realms of human experience are beyond the reach of the social forces I have emphasized in this study of AIDS.
Finally, the history of HIV in Haiti suggests that, although nonHaitians were important in the early part of the epidemic, they no longer play a major role in HIV transmission on the island. The history of HIV, when read against the stories told in the ethnographic chapters, helps to demonstrate the means by which AIDS has become a heterosexually spread disorder. Poverty puts young adults at risk of exposure to HIV, and high rates of seroprevalence have already been registered throughout urban Haiti. The preceding chapters all demonstrate the salience of rural Haiti’s ties to Port-au-Prince and the United States, and the intimacy of these links is further suggested by the short doubling time of the Haitian epidemic. Together, these findings suggest that, if a disaster is to be averted in rural Haiti, vigorous and effective prevention campaigns must be initiated at once. And although such efforts must begin, the prospects of stopping the steady march of HIV are slim. AIDS is far more likely to join a host of other sexually transmitted diseases-including gonorrhea, syphilis, genital herpes, chlamydia, hepatitis B, lymphogranuloma venereum, and even cervical cancer-that have already become entrenched among the poor.
