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Brust, John C.M. MD

Infobytes: Book Review

Dr. Brust is Professor of Clinical Neurology and Director of the Harlem Hospital Neurology Service in New York City.

Mountains Beyond Mountains: Healing the World By Tracy Kidder, 336 Pages, Random House 2003

Tracy Kidder, who won a Pulitzer Prize for The Soul of a New Machine, writes like a novelist, but his stories are true, and his latest effort, subtitled The Quest of Dr. Paul Farmer, a Man Who Would Cure the World, is astonishingly so. We first encounter Dr. Farmer conversing with an American Army captain, one of 20,000 US soldiers dispatched in 1994 to restore Haiti's democratically elected government. The assistant mayor of Mirebalais has been murdered. “Who cut off the head of the assistant mayor?” Farmer asks. “I don't know for sure,” replies the captain. “It's very hard to live in Haiti and not know who cut off someone's head,” says Farmer.

At Brigham and Women's Hospital, where Farmer is on the Harvard faculty, one of his patients, a homeless, alcoholic, HIV-positive, parenteral drug abuser, refers to Farmer as a saint. Farmer's response: “I don't care how often people say, ‘you're a saint.’ It's not that I mind it. It's that it's inaccurate. … People call me a saint, and I think, I have to work harder. Because a saint would be a great thing to be.”

Farmer's hospital in Cange, Haiti, is called Zanmi Lasante, Creole for “Partners in Health.” As described by the author, Cange is “…in one of the most impoverished, diseased, eroded, and famished regions of Haiti.” Roughly a million peasant farmers rely on Zanmi Lasante, where ambulatory care by community health workers costs $150 to $200 to cure an uncomplicated case of tuberculosis. (In the United States comparable cures cost $15,000 to $20,000.)

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Farmer studied anthropology at Duke (graduating summa cum laude) before attending Harvard Medical School. He writes books with such titles as AIDS and Accusation: Haiti and the Geography of Blame; Infections and Inequalities: The Modern Plagues; and Pathologies of Power: Health, Human Rights, and the New War on the Poor. Brigham and Women's Hospital has a Division of Social Medicine and Health Inequalities.

At Cange, Farmer performs a spinal tap on a 13-year-old girl, who screams, “Li fe-m mal, mwen grangou!” He translates: “She's crying, ‘It hurts, I'm hungry.’ Can you believe it? Only in Haiti would a child cry out that she's hungry during a spinal tap.”

Is Farmer driven by religious faith? Here is his description of what he calls “liberation theology”: “I was taken with the idea that in an ostensibly godless world that worshipped money and power or, more seductively, a sense of personal efficacy and advancement, like at Duke and Harvard, there was still a place to look for God, and that was in the suffering of the poor. You want to talk crucifixion? I'll show you crucifixion, you bastards.”



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In Lima, Peru, Farmer's treatment program for multi-drug-resistant tuberculosis defies the World Health Organization's stated policy that “MDR-TB is too expensive to treat in poor countries.” Farmer gives a speech before the International Union Against Tuberculosis and Lung Disease listing “myths and mystifications” shared by many in attendance. When the moderator refers to the speech as “provocative,” Farmer asks, “Why do you qualify my talk as provocative? I just said we should treat sick people, if we have the technology.”

Farmer paraphrases Matthew 25: “When I was hungry, you fed me. When I was thirsty, you gave me something to drink. When I was a stranger, you took me in. When I was naked, you gave me clothes. When I was sick, when I was in prison, you visited me. Then it says, Inasmuch as you did it not, you're screwed.”

Here Farmer offers his take on bureaucracy's obsession with cost-effectiveness: “One thing that comes back to me, with all this cost-efficacy crap, if I saved one patient in my whole life, that wouldn't be bad.” On his 100-hour weeks: “The problem is, if I don't work this hard, someone will die who doesn't have to. That sounds megalomaniac. I wouldn't have said that to you before I'd taken you to Haiti and you had seen that it was manifestly true.” In Cuba, which according to a WHO study has the world's most equitably distributed health care and where life expectancy is about the same as in the US, Farmer checks into a hotel in Havana: “I can sleep here. Everyone here has a doctor.”

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Touring Siberian prisons with a Russian colleague, Farmer is asked what fee he charges for his services and replies: “Alex, you idiot, what's my fee? I charge a lot for prisoners, POWs, and the destitute sick. And I really ramp it up for refugees.” To another Russian colleague: “I think of myself more as a physician than as an American. Ludmillan [a Russian physician with whom he has been treating MDR-TB in the prisons] and I, we belong to the nation of those who care for the sick.”

Here's Farmer at an international AIDS conference in South Africa debating a World Bank official who has just said that Africans must learn to curb their sexual appetites: “I want to talk about other bankers, not the World Bankers, but bankers in general. My suspicion is that they're not getting a lot of sex, because they spend a lot of time screwing the poor.”

Farmer weighs in on the impact his activities have had: “It's embarrassing that piddly little projects like ours should serve as exemplars. It's only because other people haven't been doing their jobs.” On efforts by the US government to block aid to the Haitian government of Jean-Bertrand Aristide: “I think, sometimes, that I'm going nuts, and that perhaps there is something good about blocking clean water for those who have none, making sure that illiterate children remain so, and preventing the resuscitation of the public health sector in the country most in need of it.”

Farmer makes house calls from Zanmi Lasante that sometimes require him to hike several hours. He explains: “Some would say this is a scattershot approach. We would answer, ‘Not at all.’ It's through journeys to the sick that we identify needs and problems.”

He tells Tracy Kidder: “I have fought the long defeat and brought other people on to fight the long defeat, and I'm not going to stop because we keep losing. Now I actually think sometimes we may win. I don't dislike victory.” And elsewhere: “I may be sentimental, but I'm not a goofball. I'm a hard-bitten, clinic-building, MDR-treating mother.”

“Dèyé mòn gen mòn,” translated into English as “Beyond mountains there are mountains,” is a Haitian proverb.

©2004 American Academy of Neurology