Mountains Beyond Mountains: Part III

At the end of the twentieth century, tuberculosis was killing about two million people a year, more adults than any other infectious disease except for AIDS. TB and AIDS shared what Farmer called “a noxious synergy”—an active case of one often made a latent case of the other active, too.

At the end of the twentieth century, tuberculosis was killing about two million people a year, more adults than any other infectious disease except for AIDS. TB and AIDS shared what Farmer called “a noxious synergy”—an active case of one often made a latent case of the other active, too.

At the end of the twentieth century, tuberculosis was killing about two million people a year, more adults than any other infectious disease except for AIDS. TB and AIDS shared what Farmer called “a noxious synergy”—an active case of one often made a latent case of the other active, too.

Farmer knew that meager incomes didn’t guarantee disease and early death, but the two usually went together.

First-line antibiotics exist to combat TB, but they aren’t readily available in poor countries.

He was a beefy man with a ruddy complexion and boundless energy. Father Jack had provided Farmer and other financially strapped students with small rooms in the rectory. He was a priest who insisted on getting involved in the real world. He mediated arguments among neighborhood gangs, led vigils against drug dealing, and gave rousing sermons every Sunday.

He was a beefy man with a ruddy complexion and boundless energy. Father Jack had provided Farmer and other financially strapped students with small rooms in the rectory. He was a priest who insisted on getting involved in the real world. He mediated arguments among neighborhood gangs, led vigils against drug dealing, and gave rousing sermons every Sunday.

He was a beefy man with a ruddy complexion and boundless energy. Father Jack had provided Farmer and other financially strapped students with small rooms in the rectory. He was a priest who insisted on getting involved in the real world. He mediated arguments among neighborhood gangs, led vigils against drug dealing, and gave rousing sermons every Sunday.

Whenever he returned to Boston, he strongly urged Farmer, Ophelia, and Jim to consider starting a PIH project in Lima’s slums. The biggest advocate for this bold undertaking, besides Father Jack, was Jim Kim. Farmer remained cautious about overcommitting PIH’s limited resources.

Then, in the spring of 1995, Father Jack got sick. After the priest flew to Boston, Jim drove him to the Brigham, where doctors diagnosed tuberculosis. He was put on a standard regimen of four first-line antibiotics, similar to what WHO recommended for anyone who contracted TB.

Carabayllo was a meandering, seemingly endless vista of poverty. I saw roads choked with dilapidated cars, motorcycle rickshaws, and battered minibuses that served as public transportation.

Carabayllo was a meandering, seemingly endless vista of poverty. I saw roads choked with dilapidated cars, motorcycle rickshaws, and battered minibuses that served as public transportation.

Carabayllo was a meandering, seemingly endless vista of poverty. I saw roads choked with dilapidated cars, motorcycle rickshaws, and battered minibuses that served as public transportation.

Carabayllo was a meandering, seemingly endless vista of poverty. I saw roads choked with dilapidated cars, motorcycle rickshaws, and battered minibuses that served as public transportation.

Piles of uncollected garbage, along with abandoned vehicles, dotted the banks. Some of the garbage was on fire, smoldering.

The pavement turned to dirt, then roads turned into paths, and dwellings grew increasingly forlorn and miserable.

With a fatalistic WHO setting the policy, Peruvian clinics didn’t provide expensive MDR medicines.

Farmer started treating patients in August 1996, transporting Zanmi Lasante’s TB program to Carabayllo, and tailoring it to MDR and other local circumstances. They already had a group of young Peruvians trained as community health workers, and several skilled Socios en Salud nurses, with Bayona to direct everyone. In addition, Farmer arranged for a top epidemiologist and two medical students from Harvard to live in Carabayllo and work with Socios en Salud.

Most of the “TB tribe” who knew about Farmer considered Socios en Salud’s work unorthodox and Farmer something of a maverick—a clinician too interested in individual patients to comprehend the global TB picture.

Farmer didn’t want to rile up the establishment, but he was determined to get his points across.

Myth number three: MDR was less virulent and contagious than regular TB. Mere wishful thinking, Farmer declared, basically telling his audience they didn’t know as much about MDR as he and PIH did.

Paying great attention to each patient was not only a moral imperative, he said, it was the only way to understand and control all types of TB in communities, as he’d proven in Cange and was trying to demonstrate in Carabayllo, if the Peruvian government would stop hindering his team’s efforts.

Farmer was normally a fast diagnostician, but he found himself stalling on his own case. He finally made the right guess on his last day at the Brigham, when the smell of coffee at breakfast made him nauseous. He had had a similarly strong response to pizza the night before. A classic symptom of hepatitis, he thought: revulsion at foods you love.

When his lab work came back at the end of that day, showing his liver functions at dangerously low levels, Farmer conceded he could no longer tough it out.

Slowly, the MDR project in Carabayllo, due to Jim Kim’s and Jaime Bayona’s dogged determination, was making progress with the fifty patients.

Farmer and Jim continued to share results with the Peruvian TB doctors, who began to acknowledge Socios en Salud’s successes. No one referred to Farmer as a médico aventurero anymore. Cynicism had been replaced with respect.

Bayona had had the girl’s sputum cultured and sent everything to the Massachusetts State Lab, quietly bypassing the Peruvian national lab in order to protect his friend from scrutiny.

Farmer was here today to consult, not dictate, so he diplomatically reviewed the treatment options with the doctors in the room. He finally suggested that a specific second-line therapy might be the sensible answer. This of course was his prejudice, he made clear.

In April, the same international “TB tribe” of experts—college professors, public health specialists, epidemiologists, and bureaucrats—whom Farmer had addressed in Chicago was convening in Boston at a meeting of the American Academy of Arts and Sciences.

We took on this project because we thought that by proving that one could do community-based treatment of multi-drug-resistant TB, we might have the opportunity to work with a roomful of people like you. To actually expand resources to a problem that afflicts the populations we serve.

The room seemed to be divided between applause and silence. Undaunted, Jim went on, referring to the Boston meeting as “a TB All-Star Weekend.”

He suggested that the combined resources of the attendees, using their clout to access research, publicity, and people with money, could be marshaled to defeat the worldwide menace of TB, one project at a time.

TB experts had declared MDR treatment inordinately expensive, but no one had tried to reduce the main expense, which was high-priced drugs.

Rejecting much of his midwestern upbringing, he embraced the idea of Asian “racial solidarity.” Reading for the first time about the internment camps for Japanese Americans during World War II, he went on to lecture about it.

A lot of students had joined PIH after hearing him talk. Change the world? Of course they could. He’d been with the organization for a decade by now and done a lot of its more menial chores along the way. Whatever it took to make a difference.

His presentation fell mostly on deaf ears, until a young Dutchman, who worked for a nonprofit company in Holland called International Dispensary Association, grew frustrated at the impasse. IDA specialized in driving down prices of essential drugs, the kind that the indigent sick need most urgently.
“IDA,” said the Dutchman at the meeting, “is going to do everything we can to lower prices, by exploring generic manufacturers.”

His presentation fell mostly on deaf ears, until a young Dutchman, who worked for a nonprofit company in Holland called International Dispensary Association, grew frustrated at the impasse. IDA specialized in driving down prices of essential drugs, the kind that the indigent sick need most urgently.
“IDA,” said the Dutchman at the meeting, “is going to do everything we can to lower prices, by exploring generic manufacturers.”

Jim went back to WHO, which serves as the coordinating body for virtually all of the world’s ministries of health. He began lobbying officials there to include the various second-line antibiotics on their list of “essential drugs”—a list that the ministries followed and allocated money for in their budgets.

Jim was told that various eminent TB critics had written to Geneva that they couldn’t agree with adding second-line antibiotics to the essential drug list.

The latter objection had substance, Jim knew. In the real world, many countries lacked even simple health services, and others had clinics and hospitals staffed by the ignorant, the careless, and the lazy. In the real world, some doctors peddled drugs on the black markets, desperate patients sold their antibiotics to buy food, and stupid pharmacists mixed up prescriptions.