Mountains Beyond Mountains: One doctor's quest to heal the world

by Tracy Kidder

Farmer was the medical director, but he hadn’t argued. Instead—this was often his way, I would learn—he had simply subverted the policy. Every patient had to pay the eighty cents, except for women and children, the destitute, and anyone who was seriously ill. Everyone had to pay, that is, except for almost everyone. And no one—Farmer’s rule—could be turned away.

So we’ll give him a couple hundred dollars of Ensure, and I’ll take great pleasure in violating the principle of cost-efficacy.

accusations like the woman’s always seem to spring from the jealousies that great scarcity inspires.

No one else, not at this time, is treating impoverished Haitians with the new antiretroviral drugs. Indeed, almost no one in any poor country is treating poor people who have the disease. Even some of Farmer’s friends in the Haitian medical establishment have told him he’s crazy to take on AIDS this way in Cange, and certainly many experts in international health would agree. Leaving aside all other objections, the new AIDS drugs could cost Zanmi Lasante about five thousand dollars a year per patient. Nonetheless, Farmer had started some patients on triple therapy. A few months ago, he gave a speech to a group in Massachusetts called Cambridge Cares About AIDS. “Cambridge cares about AIDS,” he told them. “But not nearly enough.” He wondered if he’d gone too far, but afterward, at his suggestion, health workers in the audience and people who themselves had AIDS collected a bunch of unused drugs, and he ended up with enough to treat a few more of his patients here in Cange. He intends to increase those numbers, he says. He and his colleagues back in Massachusetts are working on grant proposals to obtain a larger, more reliable supply. They’ll find the money, he’s told me. “Of course we’ll find the money.”

“Life-m mal, mwen grangou!” Farmer looks up, and for a moment he’s narrating Haiti again. “She’s crying, ‘It hurts, I’m hungry.’ Can you believe it? Only in Haiti would a child cry out that she’s hungry during a spinal tap.”

One health worker recited a Haitian saying: “Giving people medicine for TB and not giving them food is like washing your hands and drying them in the dirt.”

The project was intended to improve irrigation and to generate power. It wasn’t as though the peasants of the central plateau didn’t need and want modern technology, Farmer said. But, as they themselves often remarked, they didn’t even get electricity or water for their land. Most didn’t get money either. In fact, the dam was meant to benefit agribusinesses downstream, mostly American-owned back then, and also to supply electricity to Port-au-Prince, especially to the homes of the numerically tiny, wealthy Haitian elite and to foreign-owned assembly plants.

“Medicine is a social science, and politics is nothing but medicine on a large scale.

The physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.

The first microscope in Cange was a real one, which he stole from Harvard Medical School. “Redistributive justice,” he’d later say. “We were just helping them not go to hell.

They talked about the insignificance of “cultural barriers” when it came to the Haitian peasant’s acceptance of modern Western medicine: “There’s nothing like a cure for a disease to change people’s cultural values.”

It lay behind most cost-effectiveness analyses. 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, as if God had imposed poverty on places like Haiti.

Indeed, according to a study by WHO, Cuba had the world’s most equitably distributed medicine.

Moreover, Cuba seemed to have mostly abandoned its campaign to change the world by exporting troops. Now they were sending doctors instead, to dozens of poor countries.

Some people would say things will get so bad that Haitians will revolt. But you can’t revolt when you’re coughing out your lungs or starving. Someone’s going to have to revolt on the Haitians’ behalf, including people from the wealthy classes.

Farmer goes on, “If we could identify losers like John, and not waste our time and energy on them, then we’d be all good, as they say in the States. Right? But the point of O for the P is that you never do that. You never risk that. Because before you turn your back on someone like John you have to be really really sure, and the more you learn about John’s family the more you realize that the whole family, their whole—I mean, they’re basically extinct, right? He was the last kid. They’re extinct. His mother’s bloodline is just gone. It sounds Darwinian, but you know what I mean. Shit, man, how can you be an O for the P doc and be willing to take that risk without all the data you can get? Every patient is a sign. Every patient is a test. Like this guy we just saw. The guy’s living in dirt, the guy who needs Canadian crutches? You realize how much shit I’d get for that, Canadian crutches in rural Haiti?”

But standard notions of efficiency, notions about cost-effectiveness, about big people performing big jobs, haven’t worked so well themselves. Long ago in North Carolina, Farmer watched the nuns doing menial chores on behalf of migrant laborers, and in the years since he’s come to think that a willingness to do what he calls “unglamorous scut work” is the secret to successful projects in places like Cange and Carabayllo. “And,” he says, “another secret: a reluctance to do scut work is why a lot of my peers don’t stick with this kind of work.”

He’s still going to make these hikes, he’d insist, because if you say that seven hours is too long to walk for two families of patients, you’re saying that their lives matter less than some others’, and the idea that some lives matter less is the root of all that’s wrong with the world.

Often they rely almost entirely on professionals from the world’s wealthy countries, and they fail to make their projects indigenous. This all but guarantees that their projects will neither grow nor last. PIH is different. The organization now has on the order of 6,500 employees. The overwhelming majority come from the impoverished countries where PIH is working. Fewer than one hundred of the employees come from the United States.