PDF Summary:Mountains Beyond Mountains, by Tracy Kidder

Paul Farmer has worked for decades to provide health care to patients in Haiti and around the world. A doctor and anthropologist by training, Farmer saw the health of a nation’s people as a product of its culture and political history. For Haiti, centuries of political strife—often at the hands of imperialist powers—had left it one of the most impoverished countries in the western hemisphere.

Despite prevailing wisdom that it was too costly to treat patients in poor countries for diseases like drug-resistant tuberculosis and AIDS, Farmer strived to treat everyone who needed care. His multi-pronged approach included prioritizing preventive services, changing international healthcare policy, and lowering the cost of important drugs. His organization’s approach is considered a model for providing treatment to patients in poor countries.

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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.

Political Advocacy

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.

Picking Up the Pieces

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.

Treating Tuberculosis in Peru

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.

Drug Resistant Tuberculosis

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.

The Cause

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.

Obstacles to Treatment

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:

1. It was too costly to treat patients in poverty with MDR, so it shouldn’t be done.
2. MDR wasn’t super contagious, so treatment wasn’t necessary.
3. Stopping the transmission of the disease was more important than treating individual patients.

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.

Traveling to Cuba and Russia

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.

Cuba

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.

Russia

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.

Innovative Treatments for Haitian Patients

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.

Treatment in Boston: John’s Story

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.