Aids and Accusation: Haiti and the Geography of Blame PDF
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.d e vre se r sth g ir llA .sse rP a in ro fila C fo ytisre vin U .6 0 0 2 © th g iryp o C Farmer, Paul. AIDS and Accusation : Haiti and the Geography of Blame, Updated with a New Preface, University of California Press, 2006. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mtholyoke/detail.action?docID=787370. Created from mtholyoke on 2022-03-21 16:03:46. AIDS and Accusation Haiti and the Geography of Blame Updated with a New Preface Paul Farmer UNIVERSITY OF CALIFORNIA PRESS Berkeley / Los Angeles / London .d e vre se r sth g ir llA .sse rP a in ro fila C fo ytisre vin U .6 0 0 2 © th g iryp o C Farmer, Paul. AIDS and Accusation : Haiti and the Geography of Blame, Updated with a New Preface, University of California Press, 2006. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mtholyoke/detail.action?docID=787370. Created from mtholyoke on 2022-03-21 16:03:46. University of California Press, one of the most distinguished university presses in the United States, enriches lives around the world by advancing scholarship in the humanities, social sciences, and natural sciences. Its activities are supported by the UC Press Foundation and by philanthropic contributions from individuals and institutions. For more information, visit www.ucpress.edu. Comparative Studies of Health Systems and Medical Care, 33 University of California Press Berkeley and Los Angeles, California University of California Press, Ltd. London, England © 1992, 2006 by The Regents of the University of Caliornia First paperback printing, 1993 Library of Congress Cataloging-in-Publication Data Farmer, Paul, 1959- Aids and accusation : Haiti and the geography of blame / Paul Farmer.—Updated with a new preface. p. cm.—(Comparative studies of health systems and medical care) Includes bibliographical references and index. ISBN 978-0-520-24839-7 (pbk. : alk. paper) 1. AIDS (Disease)—Haiti. 2. Medical anthropology—Haiti. I. Title. II. Series. RA644.A25F37 2006 306.4'61—dc22 2005046650 Manufactured in the United States of America 15 14 13 12 11 10 11 10 09 08 07 10 9 8 7 6 5 4 3 This book is printed on New Leaf EcoBook 50, a 100% recycled fiber of which 50% is de-inked post-consumer waste, processed chlorine-free. EcoBook 50 is acid-free and meets the minimum requirements of ANSI/ASTM D5634-01 (Permanence of Paper). .d e vre se r sth g ir llA .sse rP a in ro fila C fo ytisre vin U .6 0 0 2 © th g iryp o C Farmer, Paul. AIDS and Accusation : Haiti and the Geography of Blame, Updated with a New Preface, University of California Press, 2006. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mtholyoke/detail.action?docID=787370. Created from mtholyoke on 2022-03-21 16:03:46. This book is dedicated to the memory of my father .d e vre se r sth g ir llA .sse rP a in ro fila C fo ytisre vin U .6 0 0 2 © th g iryp o C Farmer, Paul. AIDS and Accusation : Haiti and the Geography of Blame, Updated with a New Preface, University of California Press, 2006. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mtholyoke/detail.action?docID=787370. Created from mtholyoke on 2022-03-21 16:03:46. “If ever there were a society that ought to have ended up totally annihilated, materially and spiritually, by the trials of ‘modernization’ it is Haiti.” Mintz (1972:7) .d e vre se r sth g ir llA .sse rP a in ro fila C fo ytisre vin U .6 0 0 2 © th g iryp o C Farmer, Paul. AIDS and Accusation : Haiti and the Geography of Blame, Updated with a New Preface, University of California Press, 2006. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mtholyoke/detail.action?docID=787370. Created from mtholyoke on 2022-03-21 16:03:46. Contents PREFACE TO THE 2006 EDITION PREFACE TO THE FIRST EDITION 1 Introduction PART I: MISFORTUNES WITHOUT NUMBER 2 The Water Refugees 3 The Remembered Valley 4 The Alexis Advantage: The Retaking of Kay 5 The Struggle for Health 6 1986 and After: Narrative Truth and Political Change PART II: AIDS COMES TO A HAITIAN VILLAGE 7 Manno .d e vre se r sth 8 g ir llA Anita .sse rP a in 9 ro fila C Dieudonné fo ytisre vin 10 U .6 00 “A Place Ravaged by AIDS” 2 © th g iryp PART III: THE EXOTIC AND THE o C Farmer, Paul. AIDS and Accusation : Haiti and the Geography of Blame, Updated with a New Preface, University of California Press, 2006. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mtholyoke/detail.action?docID=787370. Created from mtholyoke on 2022-03-21 16:03:46. MUNDANE: HIV IN HAITI 11 A Chronology of the AIDS/HIV Epidemic in Haiti 12 HIV in Haiti: The Dimensions of the Problem 13 Haiti and the “Accepted Risk Factors” 14 AIDS in the Caribbean: The “West Atlantic Pandemic” PART IV: AIDS, HISTORY, POLITICAL ECONOMY 15 Many Masters: The European Domination of Haiti 16 The Nineteenth Century: One Hundred Years of Solitude? 17 The United States and the People with History PART V: AIDS AND ACCUSATION 18 AIDS and Sorcery: Accusation in the Village 19 AIDS and Racism: Accusation in the Center 20 AIDS and Empire: Accusation in the Periphery .d e vre se 21 r sth gir llA Blame, Cause, Etiology, and Accusation .sse rP a 22 in ro fila Conclusion: AIDS and an Anthropology of Suffering C fo ytisre NOTES vin U .6 BIBLIOGRAPHY 0 0 2 © th INDEX g iryp o C Farmer, Paul. AIDS and Accusation : Haiti and the Geography of Blame, Updated with a New Preface, University of California Press, 2006. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mtholyoke/detail.action?docID=787370. Created from mtholyoke on 2022-03-21 16:03:46. From Haiti to Rwanda: AIDS and Accusations Learning Lessons Twenty years after initiating the research on which this book is based, and almost fifteen years after seeing AIDS and Accusation in print, I am pleased that my editor has asked me to write a new preface for it. The invitation has led me to reflect not so much on the book's possible impact—some suggest that academic studies rarely have significant impact on anyone but the author—as on some of the things I've learned about AIDS and related epidemics. I had already learned some of these lessons by the time this book appeared; a few I had to unlearn, and of course I have learned a host of new lessons simply by staying engaged in settings where AIDS has taken hold. I'm writing this preface from rural Rwanda, from the middle of the continent that is currently the epicenter of the global pandemic. Even a road-tested student of social conditions and infectious disease has ample occasion to keep learning in Rwanda—and perhaps to contribute something to those most affected by AIDS. Some of the lessons I learned as a graduate student and physician in training—many of which I lay out in AIDS and Accusation—continue to be useful. First, I learned that AIDS, although a new disease, is deeply embedded in social and economic structures long in place and that violence, poverty, and inequality are the fault lines along which HIV spreads. Even when I wrote this book, those of us working with the disease saw that AIDS was likely to become a major killer of people living in poverty; that tuberculosis (a disease afflicting each of the young AIDS victims profiled in AIDS and Accusation) would likely hasten the deaths of those unfortunate enough to live in poverty and to become infected with HIV; and that much could be done, even then, to avert unnecessary suffering. The possibility for action was evident .de even before the development of life-saving antiretroviral medications. I learned how medical vre se errors, bad diagnoses, and confidently expressed but incorrect claims of causality could r sth gir llA themselves cause great suffering. Some claims came from the popular press, but many, as is .sse clear in AIDS and Accusation, came from officially accredited speakers: scientific and rP a medical authorities as well as political figures. Some authorities claimed, for example, that in ro fila HIV came to the United States from Haiti—“the little Africa off the coast of Florida” 5 C fo ytisre according to the popular press—despite the fact that data available at the time, which I review vin in this book, suggested the opposite. In AIDS and Accusation, I characterize the Haitian U .60 epidemic as a direct subepidemic, or offshoot, of the much larger U.S. pandemic—one that is 0 2 © th quite unrelated to the one in Africa. Technologies developed after this 1992 study g iryp characterized the genetic subtypes, or clades, of HIV and corroborate the thesis here: the o C Farmer, Paul. AIDS and Accusation : Haiti and the Geography of Blame, Updated with a New Preface, University of California Press, 2006. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mtholyoke/detail.action?docID=787370. Created from mtholyoke on 2022-03-21 16:03:46. Haitian epidemic is indeed caused by subtype B, the clade prevalent in the United States. AIDS did not come to Haiti from Africa, where other clades are prevalent; it came south with North American tourists. But the myth that AIDS came to the United States from Haiti prevails in the popular press and, at times, in the popular imagination. Similarly erroneous claims about the role of stigma, a traditional topic of anthropology and other social sciences, were also common. It's true that AIDS was entangled with stigma in many ways. In rural Haiti, social responses were often tied to accusations of sorcery, a system of attitudes about the etiology of suffering with deep roots in Haiti's history as a slave colony. The modern-day accusations registered in rural Haiti were almost invariably triggered by local social inequalities. Accusing someone of sorcery is a way (maladaptive, perhaps) for the victim to transfer blame for misfortune to another person, the alleged perpetrator. But in the United States and other wealthy postslavery societies of the Americas, the stigma of AIDS combined with inveterate racism to ensure that victims of the disease would bear the blame for their own misfortune. Moreover, not only sufferers from HTV but all Haitians were branded as AIDS carriers. This variety of stigma cannot be reduced to a matter of personal concern, though I have heard hundreds of anecdotes of landlords and employers acting out of prejudice and fear and have no reason to doubt their veracity. Racism was central to the early international responses to AIDS, too, and remains a problem today, as AIDS takes its greatest toll on the continent of Africa, where the heritage of colonialism and racism weighs heavily. In all these settings, however, accusation remained a constant, prompting the subtitle of this book: Haiti and the Geography of Blame. I learned that stigma, always socially constructed, works in different ways in different places and that the most important stigma in rural Haiti resulted from people's belief, correct at the time, that AIDS was an inevitably fatal disease. Stigma would later be a major barrier to the introduction of proper AIDS care when, once again, poverty and lack of access to even the most rudimentary medical care were far more likely to determine the efficacy of AIDS screening and prevention efforts than were purely clinical issues. In rural Africa as in rural Haiti, stigma is less a barrier to providing AIDS care than it is the reflection and result of a complete lack of decent health care for the poor. Stigma is a symptom of this grotesque failure but is often used as an excuse for further inaction. How often do we read, in the popular press, that stigma, rather than poor-quality services, slows HIV screening? Even today, a fundamental misunderstanding of stigma continues to hamper effective responses to the pandemic. .de Among the other central lessons laid out in this book is the fact that the mechanisms by vre ser sth which poverty and other social injustices, such as racism and gender inequality, hasten the gir llA advance of HIV and tuberculosis are knowable. Indeed, we can understand them by linking a .sse geographically broad and historically deep analysis both to ethnographic knowledge and to an rP a understanding of the epidemiology of infectious disease. The more that social inequalities in ro fila constrain individual agency, the faster HIV spreads. Also, at the time I wrote this book, the C fo ytisre epidemic was changing rapidly before my eyes, as were social conditions in Haiti, so a vin processual approach, one alive to change, seemed to be the right way to understand a new U .60 disease rooted in long-standing conditions. This book closes with a call for an “anthropology 0 2 © th of human suffering.” g iryp Perhaps these ideas sound like exactly the sort of thing a graduate student would write in a o C Farmer, Paul. AIDS and Accusation : Haiti and the Geography of Blame, Updated with a New Preface, University of California Press, 2006. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mtholyoke/detail.action?docID=787370. Created from mtholyoke on 2022-03-21 16:03:46. doctoral thesis, and AIDS and Accusation is indeed a revised and shortened dissertation. But although I could have presented these insights more elegantly, they remain valid. As some of us turn our attention, however tardily, to the poorer reaches of Africa, we learn that social conditions shape not only the epidemic itself but also social responses to it. I dared to make a few predictions at the end of this book, fairly obvious ones at the time, and I can say without triumph that they have come true. Here is how I concluded AIDS and Accusation: [I]f 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. Alas, HIV, unknown in rural Haiti in 1983 (the date of my first visit to the village I call Do Kay in this book) and indeed in most parts of the world, including rural Africa, did become the world's leading infectious cause of adult death. Tuberculosis, a completely curable disease, has now dropped to second place, and is, as in Haiti, the leading cause of death among Africans living with AIDS. I certainly take no pleasure in pointing out that a geographically broad and historically deep examination of the nascent pandemic in the 1980s showed that this disaster would occur unless vigorous and fundamentally structural interventions took place. Of course, nothing of the sort happened. Not until better treatment for these diseases was put in place and integrated with AIDS prevention did the Haitian epidemic begin to come under control. As I write this, the Haitian epidemic is at last shrinking, a major victory for public health in one of the most poverty-stricken countries on the planet.1 I've spent much of the past two decades studying these infectious killers. To be frank, however, I was never asked, in Haiti or in any of the other places in which we work (more on who “we” are in a second), to do much in the way of studying suffering. In fact, I cannot remember a single such invitation from patients or their families. Instead, we were inundated in Haiti and elsewhere with a different sort of request: to do something to allay the awful suffering associated with these infectious diseases and with the host of other problems— .d hunger, malaria, death during childbirth, mistreatment at the hands of the powerful or less e vre se impoverished—that people afflicted with the new disease, AIDS, had long faced. r sthg Partners In Health, a nongovernmental organization seeking to put into practice the ir llA .sse conviction that health care is a human right, was born in the village of Do Kay and is rooted in rP a the experiences and years of work described in AIDS and Accusation. To make a long story in ro fila short—and these past two decades have felt very long—the years described in the processual C fo ytisrevin ectahrneofuglr aspchhyo lianr sthhiips breoqouki rleesd amlle o tnoe 'cso anttteemntpiolant,e a snodm neo hgarradd ucahtoei scteusd. eOntn c tahne aofnfoer hda tnod l, oas el idfee eopf U .6 respect for careful scholarship; indeed, every graduate student has been the direct beneficiary 0 0 2 © th of one or more mentors who have dedicated their lives to careful scholarship and teaching. On g iryp the other hand, one can choose a life of service and make common cause with people struggling o C Farmer, Paul. AIDS and Accusation : Haiti and the Geography of Blame, Updated with a New Preface, University of California Press, 2006. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/mtholyoke/detail.action?docID=787370. Created from mtholyoke on 2022-03-21 16:03:46.
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