Redistributive Justice

Paul Farmer is a humble force of nature, if that's possible. He's a doctor to the poor who walks seven hours in the Haitian mountains to make a hut call, who hugs people freely and with abandon, and who travels thousands of miles a year to care for his patients. This "force," describes Tracy Kidder in his excellent Mountains Beyond Mountains, is passionate, prickly, brilliant, uncompromising, and sometimes irritating. He cajoles, begs, and borrows money and equipment for his hospital in Haiti, Robin Hood - like in his belief that places like Harvard Medical School can and should absorb the loss of drugs and supplies, or the cost of treating a Haitian boy whose body is limp from the weight of a rare cancer.

Twenty-some years ago Farmer set up Zamni Lasante (Creole for "Partners in Health"), a hospital in Cange, one of the most desolate areas of Haiti. Along with comrades John Kim and Ophelia Dahl, and with a lot of money from philanthropist Tom White, their work soon evolved into an entire community-based public health system for that area. Now Partners in Health (PIH), headquartered in Boston, operates medical projects in six other countries, treating minor ailments and major illnesses such as TB and AIDS.

It's a line of work Farmer was pursuing by his early 20s, with a combination of faith - he's particularly attracted to liberation theology and its preferential option for the poor - and realism. He has faith, he told a co-worker, but added, "I also have faith in penicillin, rifampin, isoniazid, and the good absorption of the fluoroquinolones, in bench science, clinical trials, scientific progress, that HIV is the cause of every case of AIDS, that the rich oppress the poor, that wealth is flowing in the wrong direction, that this will cause more epidemics and kill millions. I have faith that those things are true, too."

For Farmer, there aren't two worlds, or a Third World. There is one, and the accumulation of wealth in one part of the world has everything to do with misery and suffering in another. Of the microscope he stole from Harvard Medical School and took to Cange: "Redistributive justice," he said. "We were just helping them not go to hell."

MUCH OF Mountains recounts PIH's efforts to fight multidrug-resistant tuberculosis (MDR-TB). Farmer and fellow doctor-anthropologist Kim waged a long campaign against the big dogs of world health and their belief that treating people in developing countries was nearly impossible, given limited funds and facilities and sufferers' low education levels. Treatment needs to be "cost effective," they'd say, which for Farmer and Kim is a euphemistic way of saying resources are limited because it's the poor who are sick.

PIH, at that point still a relatively small operation, applied what they'd learned of MDR-TB in Haiti to the Peruvian slum of Carabayllo and, later, to prisoners in Tomsk, Russia. Their stunning results forced the World Health Organization and others to take notice and, importantly, change guidelines for treating impoverished populations, particularly for TB and MDR-TB. Secondarily, it shot PIH to worldwide prominence.

Toward the end of the book, Kidder writes of when PIH paid $20,000 to medevac a Haitian child suffering from cancer to Massachusetts General Hospital for treatment. "Couldn't that sum have helped a lot more people?" people asked pointedly. It's the energy-draining "cost-effectiveness" argument Farmer has always battled. His response is, "Why does it have to cost $20,000?" For Farmer, if you say some people should be treated and not others, Kidder writes, you're saying their lives matter less than some others', and the idea that some lives matter less is the root of all that's wrong with the world.

Mountains Beyond Mountains illustrates the power of a good story. Not many of us will read books or papers on TB rates, poverty, and global health stats. We know about inequities, and we know they're bad. But read this superbly written account about some brave, compassionate people, and it's impossible not to be changed. Kidder's writing lies gracefully on the page, as does most Pulitzer Prize-winning writing; it's clear, warm, lively, never drawing attention to itself. All the attention is focused on Farmer and his tremendous, inspiring - and yes, miraculous - work.

Molly Marsh is an associate editor at Sojourners.

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