Mountains Beyond Mountains: Part V–Postscript

In July 2000 the Gates Foundation gave Partners in Health and a cohort of other organizations $45 million—virtually everything Jim Kim had asked for—to wipe out MDR-TB in Peru.

Because Gates would give only one grant, Jim made peace with PIH’s potential or former adversaries, such as WHO’s tuberculosis branch, who would otherwise be competing for the grant.

Many nonprofits consumed 20 to 25 percent of their donations for overhead. Requests from PIH staff to be paid for working extra hours “because other institutions did it” were rebutted by Farmer. He would say, “One can never work overtime for the poor.”

Tomsk was to be the major pilot project to stop the Russian TB epidemic, the project that would show the way to controlling—in prisons, towns, and cities throughout Russia—both drug- susceptible TB and MDR. After much deliberation and discussions with Soros, Farmer and Jim agreed to take on Tomsk.

Tomsk was to be the major pilot project to stop the Russian TB epidemic, the project that would show the way to controlling—in prisons, towns, and cities throughout Russia—both drug-susceptible TB and MDR. After much deliberation and discussions with Soros, Farmer and Jim agreed to take on Tomsk.

Jim had managed to turn potential disaster into something affirmative. As he watched the generals depart in a cavalcade of cars, he smiled softly and we returned to our hotel.

A man with tousled hair and squinty eyes appeared. A translator explained he was part owner of the hotel as well as a local oligarch who controlled Siberian gas and oil fields.

After inevitable bureaucratic infighting and logistics problems, the Global Fund money—$1+ million for the central plateau, spread over five years—became available.

The dream of ending the disparity seemed far away, of course, but Farmer was trying, struggling, to make Cange into a medical oasis, to prove that equality was possible one day. His progress was fitful.

Farmer enlisted the help of a Brigham doctor in her early thirties, Serena Koenig, who had previously arranged for a young Haitian with a congenital heart defect to be flown to the States for successful treatment.

Because Farmer was so busy, Serena did almost all the work. She calculated that the hospital bill for John could run $100,000. She begged and cajoled for three weeks, and finally Mass General agreed to take the case for free.

He was shifting around, clearly trying to find a way to take the pressure off his neck. He made a gurgling sound—secretions clogging his airways. A nurse was there to suction them out so he wouldn’t suffocate.

Many had feared Farmer would be criticized for going to costly extremes to save one particular life, and that parents would besiege Zanmi Lasante with demands that their sick children be flown to Boston.

Less than a month after John died, Serena flew from Haiti to Boston with another extremely sick child, this one well enough to fly commercially, and Mass General waived the cost of the little girl’s care.

The incredible effort of moving the boy to Boston, then watching him die, later struck me as an object lesson in the difficulty of Farmer’s mission, perhaps in its ultimate futility.

Ti Jean, who has learned something about medicine and gives a portion of his paycheck to destitute patients, is also Paul’s main local male confidant—“my chief of staff,” Farmer calls him.

Since the death of John, I’ve been trying to form my question about his case. I remember a remark Farmer made to me a year ago in these hills: “You should compare suffering. Which suffering is worse. It’s called triage.”

"...So the bottom line is, why do we intervene as aggressively as we can with that kid and not with another? Because his mother brought him to us and that’s where he was, in our clinic.”

My mouth has grown so dry that I croak when I try to speak. Farmer has noticed and finds some oranges at a farmyard. I consume six in a row, sitting with my back against a tree. When we finally reach Casse, a brown and dusty, dirt-street market town made of wood and corrugated metal, Farmer feeds me Cokes. I tell him I feel much better.

Zanmi Lasante’s local health worker—a barefoot woman in a dress—shows us the way to Alcante’s farm. It’s a half-hour walk to a hut made of mud and sticks, a cook shack with a fireplace, and a field of millet. As we approach the abode, it looks forlorn and dismal.

Most of Alcante’s family has or had extrapulmonary TB, which is much harder to detect until it begins to spread, and then it can be fatal. It seems so unfair that a whole family like this is struck by one disease, Farmer laments.

I am aware that his critics would say Farmer just spent seven hours on two house calls when he could have been making an important speech to an important health organization, impacting the hearts and minds of influential people. But Farmer likes being grounded in the kind of obscurity, away from the media and spotlight, that refreshes his passion and authority; doctoring to the poor is his ultimate source of power.

There’s also a very practical reason for clambering up and down mountains, or doing anything arduous and unglamorous, what PIH-ers called “scut work.” In public health projects in difficult locales, theory often prevails over practice. Individual patients get forgotten, and what seems like a small problem gets ignored until it grows large, like MDR. “If you focus on individual patients,” Jim Kim says, “you can’t get sloppy.”

There’s also a very practical reason for clambering up and down mountains, or doing anything arduous and unglamorous, what PIH-ers called “scut work.” In public health projects in difficult locales, theory often prevails over practice. Individual patients get forgotten, and what seems like a small problem gets ignored until it grows large, like MDR. “If you focus on individual patients,” Jim Kim says, “you can’t get sloppy.”

Inaccurate data from countries with high incidences of MDR have made it difficult for pharmaceutical companies to meet demand for these drugs consistently, and therefore market prices have fluctuated.

Since its inception in 2002, the Global Fund to Fight AIDS, TB, and Malaria has spent $22.6 billion for more than a thousand programs in 150 countries, including funding PIH and other health organizations in Haiti, Russia, Peru, and Rwanda.

Learning from its lessons in Peru, Haiti, and Russia, PIH works closely with governments and their agencies to minimize political misunderstandings and to deploy their complementary resources.

While forty thousand people have been vaccinated since the epidemic began, the ultimate goal is to inoculate a hundred thousand Haitians.

Experts believe that cholera will continue to spike and ebb in Haiti until safe public water systems are available throughout the country.

Farmer’s travel schedule, like his emails and texts, offers no promise of subsiding. He continues to lecture, attend meetings and conferences, treat patients, and raise funds for PIH. In 2009, he accepted a position as United Nations deputy special envoy for Haiti, working closely with United Nations Special Envoy for Haiti Bill Clinton.