This chapter discusses the concept of an epidemiological map and the rise of TB in Haiti as a result of the military junta. An epidemiological map is based on what makes people sick and what kills them and in what numbers and at what ages. It could be color-coded into two colors: one would stand for populations that tend to die in their seventies of age-related illnesses; the other would stand for groups who on the average die ten and even forty years earlier from violence, hunger, and infectious diseases that medical science knows how to prevent and treat, if not always to cure. Farmer says there is a line dividing the two color-coded parts which he calls the epi line. Most of Haiti would bear the color of ill health, but parts of the hills above Port-au-Prince would be a patch of well-being. The map of the United States would contrast with large areas of well-being speckled with disease.
Meager incomes don't guarantee abysmal health statistics, but the two usually go hand-in-hand. Also, many of the groups who live on the wrong side of the epi divide have brown or black skin. What they all have in common is poverty - absolute poverty - meaning the lack of almost any necessity like clean water and shoes, medicine, and food.
Tuberculosis vividly illustrates the great epi divide. This is a dreadful and lethal disease if untreated. Fortunately, there are good and inexpensive first-line TB drugs existing. These drugs must be administered for several months, but they almost always cure the patient. By the end of the twentieth century, however, this disease is still killing about two million people a year, more adults than any other infectious disease than AIDS, and the two diseases share a noxious synergy, since an active case of one often makes for a latent case of the other. Unfortunately, because the disease mainly afflicts the poor side of the epi divide, the industrial nations and the pharmaceutical companies have all but abandoned any research on new technologies to cure the disease.
The disease usually options for the poor, because it is a latent bacillus that takes advantage of malnutrition, AIDS, and its ability to be passed on among people who live closely together. What's more, even with treatment, if the antibiotic is one-dose only or inadequate doses of several antibiotics, or the medicine is taken erratically, the drug-resistant form of the disease will actually grow into what doctors call MDR or multi drug-resistant TB. It's a scary disease and a serious problem in places with the fewest resources to deal with it.
MDR tends to arise where wealth and poverty are mingled, but not usually in places of near universal poverty like Haiti. However, by the mid-1990's, Farmer begins to deal with several cases of MDR in Cange. The first appears sometime during the junta, and Paul is filled with dread. He blames himself when a young man dies, but the fact is that treating MDR is tricky at best, and during the junta, he can't find the necessary medicines. However, it is a learning situation, and now he has assembled the resources to fight the disease at Zanmi Lasante, both with tools and procedures. He is curing most of the cases that appear sporadically in Cange, when in 1995, it claims a close friend who has been living in a shanty town on the outskirts of Peru.
This short chapter explains how poverty gives rise to disease, especially to TB and most horribly to MDR. It is a segue way to the following chapters which show how Partners In Health would become players in international health.