In Mountains Beyond Mountains, Tracy Kidder tells the true story of Paul Farmer, a doctor and anthropologist committed to both serving the poor and demonstrating that the health of a nation’s people is the product of its culture and political history. Kidder first met Farmer in 1994 during a political intervention in Haiti. Kidder was embedded with US Army officials who were attempting to restore a democratic leader, Jean-Bertrand Aristide, in Haiti, which had been ruled by a military junta for the previous three years.
Farmer, who operated a hospital in Haiti, came to express his grievances to the US Army officials about their plans. He considered the US partially responsible for the military junta—one of the junta’s leaders had trained in the US Army’s School of the Americas—and thought that the US cared more about its business interests than helping the Haitian people, the vast majority of whom were very poor. Farmer tried to show the officials that the locals weren’t happy with the US Army, a potentially huge problem—the Army had just 9 soldiers working to control 150,000 locals.
Kidder and Farmer happened to be taking the same flight on the way back to the states, and Kidder used the opportunity to learn about Farmer’s life. Farmer was 35 years old and worked part of the year at a hospital in Boston. For the rest of the year, he worked at his hospital in rural Haiti.
Farmer was frustrated by how many diseases around the world would be preventable if people were only given the appropriate treatment. He thought that people in the US, particularly “white liberals,” needed to recognize that big change couldn’t happen without some sacrifice on their part. For example, Farmer hoped that if someone learned about a disease afflicting the poor, they’d give money to help treat it rather than assuming it’d resolve itself.
In Haiti, there is an expression that says, “beyond mountains, there are mountains.” Though Farmer faced immense obstacles to bring care to those in need, he felt a sustained and urgent drive to deliver the best care possible.
In 2000, Kidder visited Farmer in Haiti to observe the area and the hospital he worked in first-hand.
Farmer worked in an area of Haiti where the local farmers had lost farmland due to the construction of a hydroelectric dam, the Péligre Dam, which holds back the waters of Haiti’s largest river. The US Army Corps of Engineers built it in the 1950s to provide water to agricultural businesses downstream—which were owned by the US at the time—as well as electricity to affluent Haitians and foreign-owned factories operating in the capital of Port-au-Prince.
Before the dam, people lived along the river, which had some of the best farmland in the region. They produced enough to feed their families, and then some. Once the dam was built, they were forced to relocate their farms up the steep mountainsides, where farmland was much less productive and more prone to erosion. In these conditions, they struggled to get by.
Farmer’s hospital, called Zanmi Lasante, means “Partners in Health” in Creole. It served a great need for medical care in the local area. Though there were other hospitals and clinics, many required patients to pay more than they could afford for treatment, including for the medical equipment used to treat them, like gloves. Furthermore, many clinics lacked basic sanitation.
In contrast, though the staff at Zanmi Lasante sometimes made mistakes or botched lab testing, they were able to offer more affordable services. Farmer insisted that the hospital treat nearly everyone, regardless of their ability to pay.
In rural Haiti, practitioners of most religions, including Voodooists, Catholics, and Protestants, all tended to believe that illness was caused by sorcery, or magic spells sent by enemies. Sorcery offered a method to explain the world.
From Farmer’s perspective, it made sense that, due to the general lack of knowledge and access to medicine, people would continue to believe in sorcery, a relic of French colonial history. Yet with exposure, most people accepted both modern medicine and sorcery. Some people thought of Farmer’s role in the community as similar to a Voodoo priest—he knew how to heal people. And Farmer knew many Voodoo priests who brought ill patients to his hospital for treatment.
Farmer’s early life greatly shaped his later life and career as a doctor. He grew up as one of 6 siblings. His family moved from Massachusetts, to Alabama, to Florida. His father worked as a salesman, and later as a teacher, while his mother held sales jobs.
Farmer’s family lived in humble quarters, such as a bus in a trailer park and a sailboat, for most of his childhood. The unconventional close quarters helped Farmer develop the ability to work and sleep anywhere.
Farmer was a bright child and was enrolled in his school’s gifted and talented program. He relished reading books like Lord of the Rings and started his own herpetology club. In high school, he was popular with young women, which his mother said was because he was a good listener.
Farmer accepted a full scholarship at Duke University. His first semester, he was extremely busy taking in the college experience. It was his first exposure to wealth, as many of the students there came from wealthy families, and he had access to the theater and other cultural experiences he hadn’t before.
Ultimately, Farmer realized that he was more drawn to the values he grew up with, such as helping the underdog and the truly poor, than he was to wealth. He observed the farmworkers employed near Duke, many of whom were Haitian and lived in conditions far worse than he had grown up with. He grew fascinated with Haiti and strove to learn all he could. He suspected that Haiti’s long history of being ruled by colonial or imperial interests had hurt its people.
Farmer volunteered at Duke’s Hospital and decided to apply to schools where he could earn a dual degree in medicine and anthropology. He also decided to go to Haiti before starting medical school. He reasoned that spending a year there doing anthropological and medical work would help him decide whether he liked that path.
Farmer arrived in Haiti in 1983 and began interviewing people to understand their life circumstances and politics. For example, he observed Voodoo rituals and talked with people from many walks of life. He also traveled to different towns and volunteered in hospitals.
By the 1980s, Haiti had been under the rule of the Duvalier dictatorship, which was propped up by the US and did little to fund road improvements or social services, for decades. While volunteering during this period, Farmer came to believe that elite western powers had worked to create a world that served their interests at the expense of others’.
Farmer realized that he had a fundamental conflict with only practicing anthropology in Haiti. Anthropologists generally observe people without attempting to help them or improve their lives. From Farmer’s perspective, this made little sense when there were practical health services that could greatly improve people’s quality of life.
Farmer decided to go to medical school at Harvard University to become a doctor and provide health services where they were most needed in Haiti. He’d also be able to earn a Ph.D. in anthropology.
During his years at Harvard, Farmer traveled back and forth between the US and Haiti. He selected a town in Haiti’s central plateau called Cange to set up his own hospital. He had visited the region and been shocked at how miserable the local people had seemed. There were no medical services provided in the area and many people were obviously dealing with pressing physical ailments.
Farmer envisioned a multi-level health system for Cange and the villages surrounding it:
For any ailments not addressed at these levels, people could seek treatment at his clinic in Cange, and Farmer planned to build his hospital next door.
Farmer’s thesis for medical school used evidence to show that AIDS had been brought to Haiti by sex tourists, rather than Haitians having brought it to the US, as was popularly believed in the US. He received his Ph.D. in Anthropology and his medical degree in 1990.
When the Duvalier dictatorship ended in 1986, and the Haitian Army took power, Haitians began questioning the role of their government. People had hoped that things would change with the end of the dictatorship, but instead, things seemed to stay exactly the same. They started staging demonstrations and were met with harsh crackdowns from the military, who shot demonstrators, hospital patients, and people waiting in line to vote.
Most demonstrations happened closer to the capital, but people in rural areas started to ask questions, too. For example, people started to recognize that sickness stemming from dirty water had just as much to do with the government refusing to spend money to build clean drinking water infrastructure as it did with pathogens. With this level of political engagement, Farmer thought there was potential for real change in Haitian politics.
In the late 80s, Farmer befriended a Catholic priest, Jean-Bertrand Aristide, who was a leader of liberation theology in Haiti. Aristide advocated against oppression and for the betterment of the poor, which resonated throughout Haiti. People wanted him to run for president, and he did.
At first, Farmer felt that Haitian politics was so corrupt, that there was no point. But people were genuinely excited about Aristide running, and Farmer soon thought Aristide’s campaign was a real chance to reform Haiti.
In the 1990 election, Aristide won with 67 percent of the vote and partnered with Zanmi Lasante, Farmer’s hospital, on AIDS prevention programs. But in September 1991, while Farmer was in Miami traveling to Haiti, her learned that the Haitian army had removed Aristide from power.
Because Farmer was a known supporter of Aristide, the Haitian government blacklisted him, barring him from entering the country. A Haitian priest whom he had partnered with in Cange bribed officials to take Farmer’s name off the list, and he returned to Haiti early 1992.
With Aristide out of power, the Haitian army resumed making life difficult for the Haitian people, particularly Aristide’s supporters. Farmer treated one local man who was beaten after commenting on the poor condition of the highway on the way to his village. His injuries were so severe that he likely wouldn’t have survived even if he’d been treated in a top US hospital. He died soon after.
Farmer shared the story with Amnesty International and the Boston Globe published it under someone else’s name, with the victim’s name anonymized. Farmer continued to go in between Cange and Boston, even smuggling in money to help fuel the resistance led by Aristide supporters.
Farmer wrote an opinion piece in the Miami Herald advocating for a military intervention in Haiti to restore Aristide. He reasoned that over the course of Haiti’s history, US meddling had mostly propped up leaders sympathetic to US interests. Now, the US needed to wield its power to help restore a rightfully elected democratic leader. In response, the Haitian government again banned Farmer from entering the country.
Farmer used his banishment to talk to different audiences about Haiti’s politics. He testified to a congressional committee about Haiti’s military rule, but many of the representatives were asleep, or didn’t think Farmer understood the situation. He also tried speaking to people in small towns in the south and midwestern US, including on the radio, but received push-back from people who saw Farmer as an extremist.
But some people listened to Farmer. In October 1994, the Clinton Administration helped reinstate Aristide to power, and Farmer, now allowed to enter Haiti, returned to his hospital to work.
The United Nations estimated that three years of military rule in Haiti had resulted in the deaths of 8,000 people at the hands of military forces, while more perished trying to escape the island by boat.
It had also affected the health of the Haitian people, amplifying existing public health crises. Zanmi Lasante had to interrupt its health programs, including vaccinations, clean water initiatives, and women’s health education. Many people in need of general medical attention avoided visiting the hospital unless they were extremely sick, which led to an increase in diseases like typhoid. Farmer had a long way to go to improve the health of his Haitian community.
In 1997, Farmer and Partners in Health’s work expanded beyond Haiti to Peru. Father Jack, a priest and member of PIH’s board of advisors, had decided to open a parish in a slum outside of Lima, Peru and thought PIH should open a clinic there.
In Partners in Health’s early days in Lima, Farmer thought it’d be worthwhile to look into treating tuberculosis there. From his experience in Haiti, he knew that tuberculosis (TB) tends to affect the poor, and multi-drug resistant tuberculosis (MDR) is especially prevalent when patients receive incomplete treatment.
One way MDR can develop is if a patient doesn’t complete a course of antibiotics. Some of the tuberculosis bacteria can survive, leading to complications or death. Or, if patients go through one course of antibiotics but still aren’t cured, subsequent treatment with the same antibiotics could cause them to develop MDR. But Farmer learned that Peru’s government had already worked with the World Health Organization (WHO) to address tuberculosis and had succeeded in curbing the spread of the disease. The WHO upheld Peru’s approach to the disease as a model for other developing countries, offering data that supported their success.
Then, Father Jack died from drug-resistant tuberculosis. It made Farmer suspect that there were in fact cases of tuberculosis that were improperly treated and led patients to develop and spread MDR.
One of PIH’s local health workers started trying to uncover cases of improperly treated tuberculosis. He learned that there were at least ten patients who had not been cured of tuberculosis, which pointed to drug-resistant strains in the community.
Farmer started investigating how these drug-resistant strains had developed in Lima. There, tuberculosis patients underwent directly observed treatment short-course chemotherapy, or DOTS. This meant a health provider watched patients while they took the antibiotics. Farmer used this same method in Haiti to cure TB patients. If a patient wasn’t cured during the first round of DOTS, then they were treated again with the same antibiotics plus an additional one.
Despite this program, the ten patients who weren’t cured had still become resistant to 4-5 antibiotics. Because the patients were observed taking the medicine, failure to complete the treatment couldn’t be the cause of drug resistance. The quality of the drugs had been certified, too.
The problem was that after the first round of DOTS failed to cure patients, they underwent a second round of treatment with some of the same antibiotics, and they only ended up sicker because the bacteria were resistant to one or more of the drugs. If the doctors had realized this after the first round and tried treating the patient with different antibiotics, they could have prevented the development of MDR.
There were obstacles both at the national and international level that hampered treating patients with MDR. At the national level, it was clear that the WHO guidelines weren’t effectively treating MDR, yet the WHO thought it too costly to treat MDR patients with different antibiotics and instead advocated for treating only TB patients. Ultimately, PIH reached an agreement with the government to follow the World Health Organization guidelines with the understanding that if the guidelines failed, they could take over and try their own treatment regimen. They treated over 100 people with MDR in Peru, and after two years, nearly 85 percent were cured.
At the international level, there were three prevailing ideas about treating MDR:
PIH took a two-prong approach to counteract these beliefs and the negligence they caused: changing health policy to include treating patients with MDR and lowering the cost of the drugs needed to treat it.
To change health policy, Farmer gave a speech to a convening of lung specialists, including WHO personnel, advocating for the treatment of both TB and MDR patients. He said it was a myth that MDR wasn’t contagious, and leaving it untreated could create even larger public health crises. As a result, the WHO changed its policy to include treatment of MDR patients.
The cost of the drugs used to treat MDR depended on the prominence of the companies that made them and how much of the drug they made. Bigger companies charged more for the same drugs than smaller ones. So, PIH staff members worked to convince smaller companies to produce the drugs, which lowered the costs by 84-95 percent.
In addition to his project in Peru, and some smaller side projects in the US, Farmer spent time traveling to raise money for his work in Haiti and helped develop a TB treatment program for Russia.
Despite previously losing the backing of the Soviet Union and facing an embargo from the US, Cuba didn’t let lack of funding or a history of poverty affect its citizens’ health—the country made public health a priority and created one of the most renowned health care systems in the world.
For Farmer, it represented a glimmer of hope that even poor countries can develop a robust system to give people access to healthcare, bettering the people’s quality of life. He traveled to Cuba to attend a conference on AIDS in 2000. While there, he attempted to gather leads on people who would be able to fund AIDS treatment, serve as doctors in Haiti, or help train Haitian medical students.
Farmer also traveled to Russia to help negotiate the terms of a World Bank loan to treat prisoners with TB. At the time, Russian prisoners’ risk of catching TB was 40 to 50 times higher than that of the rest of the country, and one-third of prisoners had multidrug-resistant tuberculosis (MDR).
Russian prisoners with TB were already receiving treatment thanks to funding from George Soros, a wealthy businessman and philanthropist. However, just like Peru’s initial plan, Soros’s plan focused exclusively on treating TB patients, not MDR patients. If the patients did not recover—if they had drug-resistance—they’d be given hospice treatment to make their deaths easier.
Farmer criticized the plan, saying it wouldn’t help lessen rates of TB or MDR in the country, and Soros enlisted his help to develop a new one. Soros suggested negotiating a loan from the World Bank to support such efforts. Farmer hoped that creating an effective TB and MDR treatment program in Russia would bring attention to the plight of the poor around the world.
Discussion of the loan terms centered on what portion of the funding should go to treat Russia’s prisoners versus non-prisoners. Farmer thought that since the prisoners were at higher risk, and could endanger the greater population if left untreated, half of the money should go to treating them.
But most of the World Bank negotiators thought that only 20 percent of the loan should go toward treating prisoners. They also didn’t like Farmer’s proposal to give prisoners with TB more food. But one of the negotiators approached Farmer privately and told him to ask for funding for vitamins for the prisoners—this funding could be used for food. The negotiators agreed to the new proposal, which ultimately gave extra food and 50 percent of the loan to prisoners.
Back in Haiti, Farmer and PIH continued to work on finding effective treatments for patients in need, even if the patients couldn’t afford it. This involved detailed planning and making decisions about how money should be spent.
Partners in Health occasionally worked to transport patients they couldn’t treat in Cange to Boston. One patient was a twelve-year-old boy named John who was suffering from a rare but treatable type of cancer. If the cancer hadn’t spread throughout his body, John had a 60 to 70 percent chance of survival. However, Zanmi Lasante didn’t have the right equipment to evaluate the cancer’s spread.
At first, they thought they could treat the cancer with drugs imported from the US, but they soon realized that even most hospitals in the US didn’t have the means to treat it effectively. The two Partners in Health doctors treating John opted to bring him to Massachusetts General Hospital, which agreed to provide free treatment.
After reaching Massachusetts General, they learned that John’s cancer had spread, and all they could do was to help him die comfortably. After John’s death, Farmer met with the head of pediatrics at Massachusetts General to develop a partnership where some of Farmer’s sickest patients in Haiti could come to the hospital to receive treatment for free. Ideally, they’d be able to treat patients before they reached John’s stage of decline.
After John’s death, some of the PIH staff complained that the $20,000 spent on John’s medevac flight to Boston could have been put to better use. But Farmer decided it was worth it to spend the money because there was a 60 to 70 percent chance that John could beat the disease—they didn’t have the equipment to see that John’s cancer had spread. They had to give patients every opportunity to get well, no matter the cost.
Trade-offs and all, Farmer still fought to give every patient the treatment they deserved.
In Mountains Beyond Mountains, Tracy Kidder tells the true story of Paul Farmer, a doctor and anthropologist committed to both serving the poor and demonstrating that the health of a nation’s people is the product of its culture and political history. Kidder first met Dr. Paul Farmer in 1994 during a political intervention in Haiti. Kidder was embedded with US Army officials who were attempting to restore a democratic leader, Jean-Bertrand Aristide, in Haiti, which had been ruled by a military junta for the previous three years.
Farmer, who operated a hospital in Haiti, came to express his grievances to the US Army officials about their plans. He considered the US partially responsible for the military junta—one of the junta’s leaders had trained in the US Army’s School of the Americas—and thought that the US cared more about its business interests than helping the Haitian people, the vast majority of whom were very poor.
(Shortform note: The US Army School of the Americas, now called the Western Hemisphere Institute for Security Cooperation, was founded in 1946 to train Latin American leaders in US warfare tactics. Since then, it has trained leaders who have gone on to stage coups in their home countries and establish governments sympathetic to US interests.)
Farmer also thought that the US Army should lock up a Haitian leader suspected in the beheading of the mayor of a town near Farmer’s hospital. Overall, Farmer tried to warn the US official that the locals weren’t happy with the US Army, a potentially huge problem—the Army had just 9 soldiers working to control 150,000 locals.
The army captain grew angry at Farmer’s critique of the School of the Americas and his suggestion that he should arrest the beheading suspect without due process. But Farmer argued that there was no sound legal system in place in Haiti—it didn’t make sense to follow a legal practice like due process in a largely lawless country. And unless the army arrested the Haitian leader, who was almost certainly guilty, he’d go free. When Farmer couldn’t convince the army captain, he left.
Kidder and Farmer happened to be taking the same flight on the way back to the states, and Kidder used the opportunity to learn about Farmer’s life. Farmer was 35 years old, and in addition to his degree in medicine, he had a Ph.D. in anthropology. Part of the year, he worked at a hospital in Boston, and for the rest of the year, he worked at his hospital in rural Haiti.
Later, Kidder had dinner with Farmer in Boston. He wanted to use Farmer’s knowledge of Haiti to inform his reporting on the US’s political intervention there, but he found that it was more complicated than he expected. Kidder thought the soldiers had done their duty—restoring a democratic government. However, economically, the country was not better off than before the soldiers had come in.
Kidder met up with Farmer again five years later, in 1999, to watch him work at Brigham and Women’s Hospital in Boston. He now worked as a professor at Harvard Medical School, on top of his work in Boston and Haiti.
Though Farmer appeared dignified and serious, his compassion and sense of humor with patients and coworkers soon shone through. For example, as Farmer treated a patient who was homeless, Joe, he asked him what kind of shelter or additional treatment he wanted. Joe wanted a shelter where he could be treated for his HIV but wouldn’t get penalized for drinking alcohol, which is often forbidden at shelters.
Farmer found Joe a shelter, but it still forbade drinking alcohol. But for Farmer, sheltering a patient and allowing them some vices was still preferable to them being out on the street. On Christmas, he visited his patients in the community, including Joe, and brought them presents. For Joe, it was a six-pack of beer, which he gladly received, calling Farmer a saint.
Farmer didn’t think he deserved to be called a saint. He liked the idea, but he thought he’d need to work considerably harder to merit the title.
Farmer wrote a book about the relationship between infectious disease, inequality, and access to medical technology around the world. He expressed discontent with how many diseases around the world would be preventable if people were only given the appropriate treatment.
During his work in Haiti, Farmer often slept no more than 4 hours a night because he was thinking about patients who needed treatment but weren’t getting it. More broadly, he felt ambivalent about charging for his medical care knowing that many couldn’t afford it. For him, it spoke to a greater need to improve the distribution of medicine and wealth.
Farmer also thought that people in the US, particularly “white liberals,” needed to recognize that big change couldn’t happen without some sacrifice on their part. For example, he hoped that if someone learned about a disease afflicting the poor, they’d give money to help treat it rather than assuming it’d resolve itself.
In Haiti, there is an expression that says, “beyond mountains, there are mountains.” Though Farmer faced immense obstacles to bring care to those in need, he felt a sustained and urgent drive to deliver the best care possible.
Farmer took some radical approaches to getting treatment to patients in rural Haiti, often breaking with norms in medicine at the time. He started treating patients with AIDS with newly developed antiretroviral drugs, a radical move at a time when virtually no country offered treatment to poor people with AIDS.
To do so, he worked to gather unused antiretroviral medication from people in the US and raise money to buy more. It could cost up to $5,000 per patient to treat AIDS in Haiti, but Farmer thought it was worth it.
In 2000, Kidder visited Farmer in Haiti to observe the area and his hospital first-hand.
Farmer worked in an area of Haiti where the local farmers had lost farmland due to the construction of a hydroelectric dam, the Péligre Dam. It holds back the waters of Haiti’s largest river, the Artibonite River.
The US Army Corps of Engineers built the dam in the 1950s to provide water to agricultural businesses downstream—which were owned by the US at the time—as well as electricity to affluent Haitians and foreign-owned factories operating in the capital of Port-au-Prince.
Before the dam, people lived along the river, which had some of the best farmland in the region. They produced enough to feed their families, and then some. Once the dam was built, they were forced to relocate their farms up the steep mountainsides, where farmland was much less productive and more prone to erosion.
Farmer’s hospital was called Zanmi Lasante, which means “Partners in Health” in Creole. It served a great need for medical care in the local area. Though there were other hospitals and clinics, many required patients to pay more than they could afford for treatment, including for the medical equipment used to treat them, like gloves. And many local hospitals and clinics lacked basic sanitation.
In contrast, though the staff at Zanmi Lasante sometimes made mistakes or botched lab testing, they were able to offer more affordable services. Farmer insisted that the hospital treat nearly everyone, regardless of their ability to pay.
Some of Farmer’s accomplishments included:
Farmer funded the hospital through a nonprofit organization by the same name: Partners in Health. He earned money from his job at the hospital in Boston—$125,000 per year—as well as from giving lectures and writing books. Whatever money he didn’t need to pay his bills went into funding Partners in Health.
The foundation got most of its funding from grants, including a $220,000 MacArthur Genius Grant, and one generous donor from the Boston area.
In 1999, Zanmi Lasante spent $1.5 million on treating patients, on-site and in their homes. In contrast, the author’s local hospital in the US treated roughly the same number of patients, but had an annual budget of $60 million and only treated patients on-site, not in their homes.
Each day, Farmer spent the first hour of his time at the hospital simply crossing the courtyard in front of the hospital complex. Hundreds of people gathered each morning seeking treatment, and Farmer took time to interact with anyone that approached him as he crossed. In addition to asking for treatment, people asked Farmer for favors like giving them money or sending a letter to the US on their behalf.
While Farmer crossed, he worked to spot patients that needed immediate medical attention, like a woman with gangrene in her hand. After reaching the building, he’d spend time answering emails in his office, then he’d see patients.
Patients came in with a variety of ailments, from a woman suffering from drug-resistant tuberculosis who needed pain medication, to a man who needed nutritional supplements to fight hunger.
In rural Haiti, practitioners of most religions, including Voodooists, Catholics, and Protestants, all tended to believe that illness was caused by sorcery, or magic spells sent by enemies. Sorcery offered a method to explain the world.
Sometimes, due to scarce economic resources, people accused one another of sorcery—they were jealous of what others had that they didn’t. In one case, For example, one woman was convinced that her son had sent an evil spell that resulted in the death of her other son. The accused son lived in a more modern dwelling than his mother. By accusing him of sorcery, she was saying that he didn’t care for her and this was the reason he had sent the spell to kill her other son.
Farmer had to explain to her that sorcery had not been the cause, but he didn’t attempt to explain that sorcery didn’t exist. He generally believed he’d be able to treat more people if he showed respect for their culture. It took many meetings, but eventually, Farmer helped the mother and son heal their relationship.
From Farmer’s perspective, it made sense that, due to the general lack of knowledge and access to medicine, people would continue to believe in sorcery, a relic of French colonial history. Yet with exposure, most people accepted both modern medicine and sorcery. Some people thought of Farmer’s role in the community as similar to that of a Voodoo priest—he knew how to heal people. Actual Voodoo priests also believed in Farmer’s healing abilities and brought ill patients to his hospital for treatment.
When a tuberculosis patient died under the care of Zanmi Lasante, Farmer wanted to investigate why. At the time of the death, Farmer had been in the US, recovering from a broken leg. He became determined to ensure that tuberculosis patients had a chance to survive even if he wasn’t at the hospital.
He hired the deceased woman’s family as health workers, and along with the other health workers at his clinic, asked them to discuss how the clinic’s treatment of tuberculosis patients fell short. They came up with two primary explanations, but both of them blamed patients and their circumstances:
Farmer designed a study to test these ideas. Two groups of tuberculosis patients received free treatment for TB, but the second group got extra perks, like visits from the community health workers and money to pay for childcare, food, and transportation. Farmer interviewed each study participant, asking them if they believed that sorcery caused tuberculosis. Most did.
In the group that got free medicine, but no money, only 48 percent made a complete recovery, whereas everyone in the group that got money made a complete recovery. This suggested that beliefs in sorcery mattered little in recovery. On the other hand, some extra money for expenses could make a big difference. Farmer started giving all tuberculosis patients monthly stipends they could use toward food and other goods. After that, he didn’t lose a tuberculosis patient in Haiti for 12 years.
To ensure the effectiveness of tuberculosis treatment, all patients had to agree to take their prescribed antibiotics. One time, a TB patient missed his monthly appointment, and someone needed to go check on him to ensure he was still taking his medicine. Farmer decided to do it himself.
He had to hike 3 hours on mountain trails to get to the patient’s home. It demonstrated the lengths Farmer would go to serve his patients—traversing mountains beyond mountains.
Once there, Farmer asked the patient why he had missed his appointment. It turned out that there had been a mix-up and he hadn’t received his monthly cash. However, he had continued to take his medicine, so he was considered in compliance with the program.
Farmer believed that poor patients should receive the treatment they need to thrive, even if it requires more effort from health care professionals. As with the patient who missed his doctor’s visit, this could include house visits or giving patients goods or money for food and services.
But he worried that most doctors weren’t willing to dedicate themselves to this kind of immersive medicine. They might work for a few years in a country like Haiti, but return to their home countries later to work in hospitals with better pay and more cushy living.
Instead, Farmer wanted to inspire young doctors to dig into the immersive approach, dedicating themselves to treating the world’s poor and vulnerable for life.
Reflect on Farmer’s approach to medicine.
Farmer saw the value in not trying to argue against patients’ religious beliefs. What are some of the merits of this approach? Some of the downsides?
Giving money helped patients with TB survive the disease. Describe 1-2 ways you think this approach might have helped. Are there situations in which giving patients money could have negative consequences?
Farmer includes house visits as part of his treatment programs. What are some of the benefits of this approach? Some of the downsides?
Farmer’s early life greatly shaped his later life and career as a doctor. He grew up as one of six siblings. His family moved from Massachusetts, to Alabama, to Florida. His father worked as a salesman, and later as a teacher, while his mother held sales jobs.
Farmer’s family lived in humble quarters, such as a bus in a trailer park and a sailboat, for most of his childhood. The unconventional close quarters helped Farmer develop the ability to work and sleep anywhere.
Farmer was a bright child and was enrolled in his school’s gifted and talented program. He relished reading books like Lord of the Rings and started his own herpetology club. In high school, he was popular with young women, which his mother said was because he was a good listener.
Farmer accepted a full scholarship to Duke University. His first semester, he was extremely busy taking in the college experience. It was his first exposure to wealth, as many of the students there came from wealthy families, and he had access to the theater and other cultural experiences he hadn’t before. He became a critic for the school paper and experienced high culture for the first time. He also joined a fraternity, but he left because it didn’t accept Black men.
Ultimately, Farmer realized that he was more drawn to the values he grew up with, such as helping the underdog and the truly poor, than he was to wealth. He had been raised Catholic, and in college, he was exposed to liberation theology, a branch of Catholicism that advocates helping the poor first and foremost.
Farmer observed the farmworkers employed near Duke, many of whom were Haitian and lived in conditions far worse than he had grown up with. He grew fascinated with Haiti and strove to learn all he could. He suspected that Haiti’s long history of being ruled by colonial or imperial interests had hurt its people.
Farmer volunteered at Duke’s Hospital and decided to apply to schools where he could earn a dual degree in medicine and anthropology. He also decided to go to Haiti before starting medical school. He reasoned that spending a year there doing anthropological and medical work would help him decide whether he liked that path.
He arrived in Haiti in 1983 and began interviewing people from many walks of life to understand their life circumstances and politics. . He also observed Voodoo rituals, traveled to different towns, and volunteered in hospitals.
While traveling, he came across a woman who was killed when her mango cart overturned. Farmer felt that to understand incidents like this one—a poor woman going to the market with an overloaded cart to sell food to feed her family—you have to understand how culture, history, and politics have shaped the incident.
In the case of Haiti, France—Haiti’s former colonial ruler—and later, the US, had done little to help the Haitian people and were more interested in supporting leaders that helped them preserve their own wealth.
By the 1980s, Haiti had been under the rule of the Duvalier dictatorship for decades, a dictatorship that was propped up by the US and did little to fund road improvements or social services that would support regular people like the deceased woman. Farmer theorized that this incident stood as an example of how elite western powers have worked to create a world that serves their interests at the expense of others’.
From the perspective of Haitians, God provided for them, but the actions of their leaders and colonial governments had unfairly stripped them of resources.
Farmer realized that he had a fundamental conflict with only practicing anthropology in Haiti, as he’d been doing. Anthropologists generally observe people without attempting to help them or improve their lives. From Farmer’s perspective, this made little sense when there were practical health services that could greatly improve people’s quality of life.
At the same time, he recognized that anthropology was useful for understanding people’s culture and informing approaches to medical treatment. For example, a doctor who understands the local culture can cultivate good relationships with Voodoo priests and partner with them to help people in need, whereas a doctor without this training might sour relationships with local religious leaders by being insensitive to their beliefs.
Farmer didn’t anticipate being able to ignore the suffering he saw in Haiti and resume a normal life back in the states. So, while he decided to go to medical school at Harvard University, his goal was to provide health services where they were most needed in Haiti. He’d also be able to earn a Ph.D. in anthropology at Harvard, and he’d use this training to better understand historical, cultural, and political impacts on health.
During his years at Harvard, Farmer traveled back and forth between the US and Haiti. He selected a town in Haiti’s central plateau called Cange to set up his own hospital. He had visited the region and been shocked at how miserable the local people had seemed. There were no medical services being provided in the area and many people were obviously dealing with pressing physical ailments.
First, he wanted to understand what people’s health needs were. He hired five local people and conducted a census of the households in town. The surveyors asked about the number of people living in a household, if there were recent deaths, and reasons for death.
Farmer learned that there was a high infant and maternal mortality rate. One reason for the infant death rate was exposure to stagnant water from the local reservoir. People had to hike down 800 feet to the reservoir to get water in buckets. They’d then leave it out uncovered for days before using it, which gave them diarrhea.
A group of Haitian and American engineers devised a system to transport water from the river that fed the reservoir up the side of the mountain where people could access it when needed through spigots. Once the system was in place, the infant death rate decreased.
This was just the start of Farmer’s reforms in the area. Farmer envisioned a multi-level health system for Cange and the villages surrounding it:
For any ailments not addressed at these levels, people could seek treatment at his clinic in Cange, and Farmer planned to build his hospital next door.
Farmer’s thesis for medical school used evidence to show that AIDS had been brought to Haiti by sex tourists, rather than Haitians having brought it to the US, as was popularly believed in the US. He received his Ph.D. in Anthropology and his medical degree in 1990.
When the Duvalier dictatorship ended in 1986, and the Haitian Army took power, Haitians began questioning the role of their government. People had hoped that things would change with the end of the dictatorship, but instead, things seemed to stay exactly the same. They started staging demonstrations and were met with harsh crackdowns from the military, who shot demonstrators, hospital patients, and people waiting to vote.
Most demonstrations happened close to the capital, but people in rural areas started to ask questions, too. For example, people started to recognize that sickness stemming from dirty water had just as much to do with the government refusing to spend money to build clean drinking water infrastructure as it did with pathogens.
In the late 80s, Farmer befriended a Catholic priest who was a leader of liberation theology in Haiti, Jean-Bertrand Aristide. Farmer attended Aristide’s church in Port-au-Prince after hearing him preach on the radio. Aristide advocated against oppression and for the betterment of the poor, which resonated throughout Haiti. People wanted Aristide to run for president, and he did.
At first, Farmer felt that Haitian politics was so corrupt, that there was no point. But people were genuinely excited about Aristide running, and Farmer soon thought it was a real chance to reform Haiti. But Farmer’s support came at a cost: He started getting threatening phone calls to Zanmi Lasante’s office in Port-au-Prince where he sometimes worked, possibly because he had been seen spending so much time with Aristide.
In a 1990 election, Aristide won with 67 percent of the vote and partnered with Zanmi Lasante on AIDS prevention programs. But in September 1991, while Farmer was in Miami traveling to Haiti, he learned that the Haitian army had taken Aristide out of power.
Because Farmer was a known supporter of Aristide, the Haitian government blacklisted him, barring him from entering the country. A Haitian priest whom he had partnered with in Cange bribed officials to take Farmer’s name off the list, and he returned to Haiti early 1992.
With Aristide out of power, the Haitian army resumed making life difficult for the Haitian people, particularly Aristide’s supporters. Farmer treated one local man who was beaten after commenting on the poor condition of the highway on the way to his village. His injuries were so bad that he likely wouldn’t have survived even if he’d been treated in a top US hospital. He died soon after.
Farmer shared the story with Amnesty International, and the Boston Globe published it under someone else’s name, with the victim’s name anonymized. Farmer continued to go in between Cange and Boston, even smuggling in money to help fuel the resistance led by Aristide supporters.
But the military was getting bolder in its tactics. One night, soldiers wandered through the Zanmi Lasante grounds. Another time, a soldier approached the hospital with a gun. When Farmer told him he couldn’t bring a gun there, the soldier grew upset with him, asking who he was to give him orders. Farmer responded that he’d be the doctor to treat him or his family members if he ever got ill. The soldier left, but he was disgruntled, and the hospital staff wanted Farmer to keep a lower profile.
Farmer’s political advocacy was just taking flight. In 1994, he published a book called The Uses of Haiti describing the oppressive history of the US toward Haiti, which included:
After the book’s publication, Farmer wrote an opinion piece in the Miami Herald advocating for a military intervention in Haiti to restore Aristide. He reasoned that over the course of Haiti’s history, US meddling had mostly propped up leaders sympathetic to US interests. Now, the US needed to wield its power to restore a rightfully elected democratic leader. In response to Farmer’s advocacy, the Haitian government once again banned him from entering the country.
Farmer used his banishment to talk to different audiences about Haiti’s politics. He testified to a congressional committee about Haiti’s military rule, but many of the representatives didn’t think Farmer really understood the situation. Other reps were so apathetic that they slept during the presentation. Farmer also tried speaking to people in small towns in the south and midwestern US, including on the radio, but he received push-back from people who saw Farmer as an extremist.
But some people listened to Farmer. In October 1994, the Clinton Administration helped reinstate Aristide to power and Farmer returned to his hospital to work.
The United Nations estimated that three years of military rule in Haiti had resulted in the deaths of 8,000 people at the hands of military forces, while more perished trying to escape the island by boat.
It had also affected the health of the Haitian people, amplifying existing public health crises. Zanmi Lasante had to interrupt its health programs, including vaccinations, clean water initiatives, and women’s health education. Though the clinic was one of the only clinics to treat victims of military violence, many people in need of general medical attention avoided visiting unless they were extremely sick.
Some of the effects of junta rule visible at Zanmi Lasante included:
To pick up the pieces, Farmer and Zanmi Lasante had a long road ahead of them.
Reflect on the role of the US in Haiti.
Why would the US involve itself in the affairs of countries like Haiti?
The US helped France prevent the uprising of Haitians against France in the 1790s. Do you think the US has a responsibility to help countries whose politics it has disrupted? Why or why not?
In 1997, Farmer and Partners in Health’s work expanded beyond Haiti to Peru. Father Jack, a priest and member of PIH’s board of advisors, had decided to open a parish in a slum outside of Lima, Peru and thought PIH should open a clinic there.
A long-time colleague of Farmer’s at Partners in Health, Jim Yong Kim, worked to establish the clinic, modeling it after Zanmi Lasante. Farmer advised Kim while working from Haiti.
Just as Farmer had in Haiti, Kim conducted a health census to find out what the community needed. Community members asked for a pharmacy where medicine could be dispensed. Shortly after the pharmacy’s completion, it was bombed by guerrilla leaders who were in a civil war with the government. The guerrillas thought that the pharmacy offered helpful medicines and services that would pacify locals to the point that they wouldn’t support the guerrilla’s cause to force change from Peru’s government.
Kim opted to rebuild the pharmacy in another location.
In Partners in Health’s early days in Lima, Farmer thought it’d be worthwhile to look into treating tuberculosis there. From his experience in Haiti, he knew that tuberculosis tends to affect the poor, and multi-drug resistant tuberculosis (MDR-TB, or just MDR) is especially prevalent when patients receive incomplete treatment.
One way MDR can develop is if a patient doesn’t complete a course of antibiotics. Some of the tuberculosis bacteria can survive, leading to complications or death. Or, if patients go through one course of antibiotics but still aren’t cured, subsequent treatment with the same antibiotics could cause them to develop MDR.
Farmer’s plans to focus on TB shifted when he learned that Peru’s government had already worked with the World Health Organization (WHO) to address tuberculosis and had succeeded in curbing the spread of the disease. The WHO upheld Peru’s approach to the disease as a model for other developing countries, offering data that supported their success.
Then, Father Jack died from drug-resistant tuberculosis. It made Farmer suspect that there were in fact cases of tuberculosis that were improperly treated and led patients to develop and spread MDR.
One of PIH’s local health workers started trying to uncover cases of improperly treated tuberculosis. By asking around at local hospitals, he learned that there were at least ten patients that had not been cured of tuberculosis, which pointed to drug-resistant strains in the community.
Farmer started investigating how these drug-resistant strains had developed in Lima. There, tuberculosis patients underwent directly observed treatment short-course chemotherapy, or DOTS. This meant a health provider watched patients while they took the antibiotics. Farmer used this same method in Haiti to cure TB patients. If a patient wasn’t cured during the first round of DOTS, then they were treated again with the same antibiotics plus an additional one.
Despite this program, the ten patients who weren’t cured had still become resistant to 4-5 antibiotics. Because the patients were observed taking the medicine, failure to complete the treatment couldn’t be the cause of drug resistance. The quality of the drugs had been certified, too.
The problem was that, after the first round of DOTS failed to cure patients, they underwent a second round of treatment with some of the same antibiotics, and only ended up sicker because the bacteria were resistant to one or more of the drugs. If the doctors had realized this after the first round and tried treating the patient with different antibiotics, they could have prevented the development of MDR.
If a patient didn’t get better after two rounds of treatment, Peru’s national treatment program refused to treat them further. They could try to get treatment through private medical practices, but it was so expensive, they’d need to sell most of their possessions to pay for it, and often couldn’t afford enough of the medicine needed to cure themselves.
There were other obstacles, both at the national and international level, that hampered treating patients with MDR.
Farmer started making regular visits to Peru to learn how to improve TB and MDR treatment. In Peru, there were two main obstacles to treating MDR:
To address these obstacles, Farmer and his team pursued two main approaches:
Amongst international medical professionals at this time, there were three prevailing ideas about treating MDR:
In response to these beliefs, Farmer and Kim devised two main ways to effectively treat TB and MDR around the world: pushing to treat patients with MDR and lowering the drug costs.
Farmer gave a talk at a convening of lung specialists, which included WHO personnel, to argue the case for treating MDR. He wanted to dispel the myth that treating MDR was not cost-effective. He used an example of a patient with MDR in Texas who spread it to 9 family members. It cost $1 million to treat the whole family. This example demonstrated that patients with MDR aren’t less contagious, and it’s more cost-effective to treat one person than multiple.
He also argued that continuing to rely on the DOTS regimen to treat TB patients and MDR patients would amplify drug resistance. In other words, not only would MDR patients not respond to this regimen, their bacteria would continue to grow in resistance.
Later, Farmer presented these ideas to the WHO directly, convincing the director of its TB program to implement a program that went beyond DOTS to treat both TB and MDR patients. The director called it DOTS-plus.
PIH had succeeded in treating TB in Peru thanks to generous donations from one major donor and others to finance the cost of the drugs. But Kim realized that a more long-term solution was needed to lower the cost of the antibiotics themselves, particularly the ones MDR patients needed.
Drug prices depend on the quantities made and the companies making them. Big companies often charge more money for a drug than smaller companies that make the same drug. If they could find smaller drug companies that already made the antibiotics, or convince small companies that didn’t make them to start, they could reduce costs by around 95 percent.
They realized it would be easier to convince smaller drug companies to make the antibiotics if the WHO designated the medicines as “essential.” Despite the prevalence of TB in the world, the drugs weren’t listed as “essential” because they were infrequently used relative to other more common drugs. Members of the WHO considered it dangerous to list the drugs as essential because it would lower the costs and make them widely available, potentially fueling antibiotic resistance.
But Kim argued that as they’d witnessed in Peru, drug resistance was already a phenomenon, and would merely get worse without access to appropriate, inexpensive drugs. Kim also advocated for the creation of a committee to control the distribution of the antibiotics used to treat MDR patients—any project attempting to treat TB or MDR patients had to have an already established plan for treating TB and minimizing drug-resistance.
The WHO agreed to add the antibiotics to its essential list, which in turn led to more small manufacturers making the drugs and the costs dropping 84-95 percent.
Despite the major changes to treatment and drug costs, the continued survival of PIH as a nonprofit was in jeopardy. The organization had largely relied on the wealth of one major donor to finance much of its operations, and the donor had spent most of his wealth.
Now that they had helped advance TB treatment in Lima, Kim envisioned expanding treatment to the rest of the country, with help from larger benefactors like the Gates Foundation. In 2000, PIH received a $45 million, 5-year grant from the Foundation to treat all MDR patients in Peru and reach an 80 percent cure rate, just as they’d done in Lima. Eventually, Kim hoped to expand their TB treatment program to other countries that needed it.
In addition to his project in Peru, and some smaller side projects in the US, Farmer spent time traveling to raise money for his work in Haiti and helped develop a TB treatment program for Russia. Even in less-busy months, he spent ample time traveling the world to do this work.
Despite previously losing the backing of the Soviet Union and currently facing an embargo from the US, Cuba didn’t let lack of funding or a history of poverty affect its citizens’ health—the country made public health a priority and created one of the most renowned health care systems in the world.
For Farmer, it represented a glimmer of hope that even poor countries can develop a robust system to give people access to healthcare, bettering the people’s quality of life. He traveled to Cuba to attend a conference on AIDS in 2000. While there, he attempted to gather leads on people that would be able to fund AIDS treatment, serve as doctors in Haiti, or help train Haitian medical students. He cultivated a number of leads in anticipation of only 1-2 coming to fruition. Sometimes he got an answer right away: One doctor agreed on the spot to allow two Haitian medical students to study at a new Cuban medical school that year.
Farmer was inspired by how Cuba handled the AIDS crisis. Their approach was fundamentally different from the US’s approach. In Cuba, AIDS patients were placed in quarantine in a large estate under military supervision. They received meals and medical treatment, though treatment from soldiers may have been harsh at first. Gradually, patients were allowed to leave quarantine periodically if they committed to having safe sex. Eventually, the doctors opted to end the quarantine, but many patients chose to stay at the center because of the nice conditions it offered. During this period, the country also made HIV testing mandatory.
By the year 2000, Cuba had the lowest per capita rate of infection in the western hemisphere. In contrast, though the infection and death rate in the US had dropped, a larger percentage of people in the US were infected and died than in Cuba. For Farmer, this demonstrated that treating AIDS could be done even in a country with limited resources.
The US had run its own quarantine for Haitians infected with HIV at Guantánamo Prison in Cuba, and Farmer had gotten to interview them about their experience. They reported being offered spoiled food that had maggots in it, and being beaten if they refused shots of the birth control Depo-Provera. Farmer grew angry after reading an account that said that the US quarantine of Haitians with AIDS at Guantánamo was the same as the Cuban quarantine.
The US government ruled the quarantine unconstitutional, ending it in 1993.
Farmer also traveled to Russia to help negotiate the terms of a World Bank loan to treat prisoners with TB. At the time, Russian prisoners’ risk of catching TB was 40 to 50 times higher than that of the rest of the country, and one-third of prisoners had multidrug-resistant tuberculosis (MDR). In some instances, people were infected while waiting years in prison before sentencing, or were released while still battling the disease, furthering its spread.
Russian prisoners with TB were already receiving treatment thanks to funding from George Soros, a wealthy businessman and philanthropist. However, just like Peru’s initial plan, Soros’s plan focused exclusively on treating TB patients, not MDR patients. If the patients did not recover—if they had drug-resistance—they’d be given hospice treatment to make their deaths easier.
Farmer criticized the plan, saying it wouldn’t help decrease rates of TB or MDR in the country, and Soros enlisted his help to develop a new one. Soros suggested negotiating a loan from the World Bank to support such efforts. Farmer hoped that creating an effective TB and MDR treatment program in Russia would bring attention to the plight of the poor around the world.
Discussion of the loan terms centered on what portion of the funding should go to treat Russia’s prisoners versus non-prisoners. Farmer thought that since the prisoners were at higher risk, and could endanger the greater population if left untreated, half of the money should go to treating them. He’d spent the better part of a year meeting with World Bank leaders, trying to sway them.
But most of the World Bank negotiators thought that only 20 percent of the loan should go toward treating prisoners and the rest should fund treatment for the general population. They also didn’t like Farmer’s proposal to give prisoners with TB more food. But one of the negotiators approached Farmer privately and told him to ask for funding for vitamins for the prisoners, which could be used for food later instead. The negotiators agreed to the new proposal, which ultimately gave extra food and 50 percent of the loan to prisoners.
Back in Haiti, Farmer and PIH continued to work on finding effective treatments for patients in need. This involved detailed planning and making decisions about how money should be spent.
Though antiretroviral drugs provided a proven treatment for AIDS, many world health experts at the time didn’t think it was practical to treat people in poor countries. They said the treatment was too costly and preferred to focus funding on prevention efforts instead. But Farmer and PIH believed in treating AIDS regardless of cost or the patient’s ability to pay.
However, Farmer encountered significant obstacles as he tried to treat AIDS patients in Haiti. One pillar of Zanmi Lasante’s AIDS program was trying to prevent the spread of HIV from mothers to babies. This one program alone required massive coordination, including providing educational programs to people in a 400 square-mile area, as well as drugs to pregnant mothers, and later, to their newborn babies.
Another obstacle to treatment came from the US leaders, who were discouraging foreign leaders and international agencies from giving Aristide’s government funding for infrastructure and services. The reasons the US acted this way were unclear, but it might have been due to a distrust of Aristide and waning interest in sending Haiti resources. As a result, many health clinics lacked money to keep operating and shut down. Zanmi Lasante became the only hospital in the region around Cange, and it had to treat even more patients.
Farmer wrote about his program in a medical journal, and he started receiving inquiries about how to replicate it. Despite the obstacles, he hoped this model could serve as a blueprint for AIDS treatment throughout Haiti and in other countries.
Partners in Health occasionally worked to transport patients they couldn’t treat in Cange to Boston. One patient was a twelve-year-old boy named John who was suffering from a rare but treatable type of cancer. If the cancer hadn’t spread throughout his body, John had a 60 to 70 percent chance of survival. However, Zanmi Lasante didn’t have the right equipment to evaluate the cancer’s spread.
At first, they thought they could treat the cancer with drugs imported from the US, but they soon realized that even most modern hospitals didn’t have the means to treat it effectively. The two Partners in Health doctors treating John opted to bring him to Massachusetts General Hospital, which agreed to provide free treatment. It took about a month from the time of his diagnosis to arrange a flight for him to Massachusetts General.
John was not in good condition to make the trip—he had been relying on a breathing tube and needed periodic suctioning to keep his airways clear. The two PIH doctors had planned to fly with him on a commercial flight to Boston, but he looked so sickly that they worried that he wouldn’t be let on the plane. Instead, they consulted with Farmer, who gave them permission to arrange a private medevac flight to transport him.
To get John to Boston, they first needed some way to transport him from Zanmi Lasante to the capital, where the medevac would depart. They found an ambulance operator with an electric suctioning device to help John make the trip safely, but the ambulance broke down on its way from Port-au-Prince to Cange. Instead, they were able to transfer the electric suctioning device to Zanmi Lasante’s vehicle and made it to Port-au-Prince.
After the medevac flight, they reached Massachusetts General and learned that John’s cancer had spread too much. All they could do was to help him die comfortably. After John’s death, Farmer met with the head of pediatrics at Massachusetts General to develop a partnership where some of his sickest patients in Haiti could come to the hospital to receive treatment for free. Ideally, they’d be able to treat patients before they reached John’s stage of decline.
When deciding how to treat John, Farmer had triaged the situation. There are two main definitions of the word “triage,” depending on the circumstances the doctor operates in:
But Farmer held treatment for the poor in the highest regard, and employed a treatment-for-all approach—closer to #2—even though his program was perpetually underfunded and supplies were limited.
Though he strived to provide treatment for all, Farmer admitted that sometimes there were trade-offs. For example, after John’s death, some of the PIH staff complained that the $20,000 spent on John’s medevac flight to Boston could have been put to better use. But Farmer decided it was worth it to spend the money because there was a 60 to 70 percent chance that John could beat the disease—they didn’t have the equipment to see that John’s cancer had spread.
Trade-offs and all, Farmer still fought to give every patient the treatment they deserved.
Back in Cange, a young boy named Alcante showed symptoms similar to John’s, but he didn’t have the same rare cancer and responded to drugs. His condition was diagnosed as scrofula, which usually occurs when a parent transmits TB to their children.
As a precaution, Farmer brought all of Alcante’s family into the hospital to assess their TB exposure. Alcante’s dad and a few of his siblings had it and were put on treatment. Farmer then decided to visit the family’s home in the town of Casse to learn if there were any conditions that made the family vulnerable to TB. He discovered two:
This process sums up Farmer’s general approach to medicine: Treat the patient, then treat the underlying causes or conditions of their illness.
Assess Farmer’s approach to treating patients.
Think of a time you had to make a decision involving a significant trade-off. What did you ultimately decide and why?
How did you feel about your decision later?
Do you think Farmer’s definition of triage—treating most patients despite limited resources—makes sense? Why or why not?
Do you think Farmer made the right decision in bringing John to Boston? Why or why not?