Meanings Beyond Mountains:
A Glossary of Terms from the Work of Paul Farmer

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)

Index         Study Notes

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)

Index         Study Notes

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)

Index         Study Notes

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)

Index         Study Notes

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)

Index         Study Notes

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)

Index         Study Notes

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)

Index         Study Notes

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)

Index         Study Notes

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 policy-makers 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)

Index         Study Notes

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 so-called “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 meta-geographical 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)

Index         Study Notes

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 re-mapping 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)

Index         Study Notes

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 Post-Conflict 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/index.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)

Index         Study Notes

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)

Index         Study Notes

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 re-emerging. 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 scale- from 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)

Index         Study Notes

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 sulfur-containing 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)

Index         Study Notes

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. Drug-resistant 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/377501-1114188195065/WBMalaria-GlobalStrategyandBoosterProgram-June2005.pdf, accessed 7/27/06).

Sunil Aggarwal (sunila@u.washington.edu)

Index         Study Notes

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:

• 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
• 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 index)

Resources for Further Study

Joralemon D. (2006). Exploring Medical Anthropology, Second Edition. Boston: Allyn & Bacon.

Janelle Taylor (jstaylor@u.washington.edu)

Index         Study Notes

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:

• 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 index)

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)

Index         Study Notes

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)

Index         Study Notes

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)

Index         Study Notes

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).
(return to index)

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)

Index         Study Notes

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 market-mediated 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)

Index         Study Notes

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 free-market liberalization represents the forward movement of history. This, for example, is the take-home 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 cost-efficacy” (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/index.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)

Index         Study Notes

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)

Index         Study Notes

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 spatially-distributed 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 human-environment 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)

Index         Study Notes

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)

Index         Study Notes

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)

Index         Study Notes

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/index.html

Michelle Bilodeau (micheb3@u.washington.edu)

Index         Study Notes

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)

Index         Study Notes

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)

Index         Study Notes

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)

Index         Study Notes

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, health-care 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, 104-105). 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)

Index         Study Notes

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)

Index         Study Notes

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 director-general 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)

Index         Study Notes

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)

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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 Geneva-based 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.

Matthew Sparke (sparke@u.washington.edu)

Index         Study Notes

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