Summary

During his years at medical school, Farmer had boarded at St. Mary of the Angels run by a parish priest known as Father Jack. The church was in Roxbury, one of Boston's run-down neighborhoods, and largely African American. His sermons had the feeling of a revival meeting, and he would declaim on poverty and injustice, with voices in the congregation calling out amen's. He was also on the board of PIH. In the early 1990's, he left St. Mary's for a place called Carabayllo, a slum on the outskirts of Lima, Peru. Now on visits back to Boston, he is telling Paul that PIH should start a project in his new parish. Jim Kim agrees eagerly.

Jim has happily served Paul for eight years as his second in command, but now he wants to do more, by learning how to do what Paul had done in Haiti. At first, Farmer is not enthusiastic, but eventually, he gives in and gets Tom White to contribute $30,000, half the initial cost of the project. And he gives Jim advice and encouragement almost daily. Jim plans to imitate a part of Zanmi Lasante: he'd create a system of community health workers in Carabayllo which they'd called Socios en Salud, but he wasn't thinking small. He envisions a project so well-designed and managed that it would inspire inspiration in other peri-urban slums all over the world. One of the first systems he implements is a pharmacy which various leaders in Carabayllo had requested. They build it right next to Father Jack's church. Unfortunately, there is a civil war going on between the government forces and the Shining Path guerrilla movement. The guerrillas have their own idea of what is best for the slums, so on New Year's Eve, while Jack is saying mass, there is a large explosion destroying the pharmacy. The Shining Path takes credit, saying that it represents crumbs for the poor, which to them is a way to curb the growth of revolutionary fervor. Paul and Jim are philosophical and just rebuild the pharmacy in another spot.

Farmer also travels to Peru to help Jim conduct a health census in the slum. He finds many of the same kinds of problems there as in Haiti, but none as acute. Naturally, he wonders if TB is a problem there and is encouraged to learn that the country has created a nationwide program with the help of the World Health Organization, which declares that the new program is the best in the developing world. Once he reads the official data, Farmer agrees and decides the one thing they don't need there are TB programs. Then, Father Jack gets sick and flies to Boston for treatment in May, 1995. He is diagnosed with TB, and they put him on the standard regimen. Unfortunately, Jack dies a month later. He had developed drug resistant TB, impervious to all five TB drugs.

Paul is inconsolable once again at the loss of a friend. However, he knows that the clinical facts of Jack's death are what matters now. They have happened upon something much more complicated and also more significant and maybe even more frightening than they thought. In order for Jack to have caught MDR, he would have had to have caught it from someone else, most likely in Carabayllo. Unfortunately the official records show nothing, and so Jaime Bayona, the project director, sets to work to dig deeper. He is introduced to a woman named Senora Brigida, who in telling her story, exposes a system reluctant to admit that MDR exists in Lima. Jaime tells the Paul the story just as he is catching a plane for Miami. Paul realizes, as he ponders information on the flight, that Peru must now step up and pay attention to the problem. Unfortunately, to Jaime Bayona, it seems the government is doing exactly the opposite. When he tries to gain access to patient records, he has to rely on sympathetic health workers who say that they have something that might interest him, but they aren't allowed to show him. So they open the file to the records and walk away and Jaime teaches himself to read them upside down. Then, he hurries and types up the information to send in e-mails to Jim and Paul.

Notes

The program in Carabayllo becomes PIH's first foray outside of Haiti. Theyu face many of the same problems there, including government reluctance to admit the truth about the TB problem, but they also realize they aren't nearly as acute. That is, until Father Jack dies of MDR and a new puzzle must be solved.